Vol.2, No.7, 811-818 (2010)
Copyright © 2010 SciRes. Openly accessible at http://www.scirp.org/journal/HEALTH/
Working with adolescents with mental disorders:
the efficacy of a multiprofessional intervention
Gatta Michela1*, Pertile Riccardo2, Testa Costantino Paolo3, Tomadini Paola1,
Perakis Ecaterini4, Battistella Pier Antonio3
1Pediatrics Department, University of Padua, Padua, Italy; *Corresponding Author: michela.gatta@unipd.it
2Department of Medicine and Public Health, Section of Psychiatry and Clinical Psychology, University of Verona, Verona, Italy
3Neuropsychiatric Unit for Children and Adolescents, ULSS 16, Padua, Italy
4Neuropsychiatric Unit for Children and Adolescents, ULSS 9, Treviso, Italy
Received 4 March 2010; revised 9 March 2010; accepted 15 March 2010.
The aim of this work was to compare multipro-
fessional and uniprofessional interventions ap-
plied to adolescent patients affected by psychi-
atric disorders. The initial hypothesis is that a
multiprofessional intervention is more efficacy
than a single one. A hundred individuals, 66
males and 34 females, aged between 12 and 19
years affected by emotional and behavioural
problems, were selected and divided into 5
groups under the therapeutic treatment. Sub-
jects, after diagnosis (ICD 10) and therapeutic
suggestion, were clinically followed for 12 mo-
nths. The Global Assessment Functioning Scale
(GAF) w as used to evaluate therapeutic efficacy
of interventions. The outcome is associated
with the type of intervention: who got clinically
better are those patients who underwent multi-
professional integrated therapy rather then a
single intervention.
Keywords: Adolescence; Psychopathol ogy;
Interprofessional Intervention; Compliance;
The approaches to problems concerning mental health
can historically be grouped into three theoretical-meth-
odological systems: the psychological one, the bio-phar-
macological one and the socio-environmental one. The
operators have often the tendency to ideologically sup-
port one the above approaches thus emphasizing a di-
chotomy which originates from an old separation be-
tween body and mind and between ind ividual and setting.
According to this trend the therapist with biological
education often tends to reduce everything to choosing
the appropriate drug to eliminate the symptom. The
therapist with psychological education is only interested
in giving the patient the most suitable interpretation for
putting him in the condition to overcome the symptom;
while the educational therapist tends to search for the
breakdowns of social nature which are considered the
cause of the pathological behaviors, in order to suggest
more adequate relational models. Everyone penned in
his own shell often mistrusts the other approach running
the risk of misunderstanding the patient’s needs and of
carrying out partial or ineffective interventions.
Many studies scrutinized and compared the benefits of
distinct treatment settings for different psychopathologies
(psychosis, eating disorder, mood disorder, behavioural
problems, ADHD, etc) and reviewed the different treat-
ment modalities that have proven h elpful in the manage-
ment of young patients [1-5]. Although different treat-
ment settings, a multi-modal treatment approach com-
prising individual psychotherapy, pharmacology and
family-based interventions are emphasised and recom-
mended, nevertheless, evidence-based findings on the
effect of different treatment methods are limited [6-9].
2. AIM
This work evaluates different ways of approaching ado-
lescents with mental disorders. Its aim is that of com-
paring multiprofessional intervention s with interventions
based on a single ap proach and analyzin g their therapeu -
tic efficacy. The initial hypothesis is that a multiprofes-
sional intervention is more efficient than an intervention
based on a single approach. Moreover the authors want
to study the influence that linkage variables such as
psychiatric diagnosis, timing of intervention, therapeutic
compliance, patients’ participation, have with different
types of treatments (educational, psychological and psy-
M. Gatta et al. / HEALTH 2 (2010) 811-818
Copyright © 2010 SciRes. Openly accessible at http://www.scirp.org/journal/HEALTH/
chiatric ones) and different associations of treatments.
The Neuropsychiatric Unit the patients were referred to,
is a second level service which treats medium-severe
psychopathological disorders. The structure provides for
services characterized by different types of interventions
(psychodynamic oriented psychotherapy, educational
treatment, pharmacological therapy) chosen according
both to the judgment of the specialist who visit the pa-
tient and to the service’s vacancy at that moment. To
verify the efficacy of different treatments, it has run a
retrospective study which has analysed those treated
patients for whom one year follow up was available.
Patients consecutively undergone one of the three treat-
ments (single or in association) during a six months pe-
riod were 112 individuals. The period is not very long to
limit the unhomogeneity of the sample. One year follow
up was available for 100 out of 112 subjects.
The psychiatric disorders of the subjects were diag-
nosed according to ICD 10 [10]. After diagnosis, patie nt s
were suggested to undergo therapeutic treatment, on the
basis of the understanding and written consent of each
subject and his/her parents. Three kinds of treatment
were applied: psychological one (psychotherapy with
interviews once a week or twice a month, with psycho-
dynamic orientation), psychiatric one (pharmacotherapy
antidepressant or atypical antipsychotic drugs and clin-
ical monitoring with one to three p sychiatric visits every
three months) and educational one (various activities
such as theatre/expressive-painting/motility in team and
manual laboratories, mediated by educational operators,
where the patient can experience his/her abilities and
limits individually or in group). These interventions
were adopted singularly or in association (two or three
of them). Patients were tested before and after the treat-
ment. The Global Assessment Functioning Scale (GAF)
[11,12] and Youth Self Report (YSR 11-18) [13-15] were
used to evaluate therapeutic efficacy of interventions 12
months after the beginning. With respect to the GAF
scale, patients were considered clinically improved,
worsened or unvaried depending on the scoring reported
during the retest (a difference in score of at least 10
points was required to define improvement or aggrava-
tion, otherwise the patient was considered unvaried).
Clinical evolution was statistically studied in relation to
other variables: psychiatric diagnosis, timing of inter-
vention, therapeutic compliance, patients’ participation,
type of interventio n.
Psychiatric diagnosis was formulated according to
ICD 10 [10] which is the manual of mental health disor-
ders used by clinicians of the Neuropsichiatric Unit of
Padua. Timing of intervention considered a period time
less then three months, a period time between three and
nine months and a period time longer then nine months.
Therapeutic compliance was divided and named in
‘adequate’ (when the patient started therapy and main-
tain it in accordance with the therapist), ‘discontinuous’
(when the patient was partially compliant, missing at
least two sessions consecutively, at least once every
three months) and ‘with interruption’ (when the patient
dropped out precociously or did not follow the therapeu-
tic indications at all). Patient’s participation was evalu-
ated on the basis of patient-therapist interaction verified
throughout th e analysis of clinical files, reports and min-
utes of sessions, interviews and equips: the WAI-O
(Working Alliance Inventory-Observer version) trans-
lated into Italian language [16-18] was used. WAI-O
ratings for each patient were assigned by an external
clinician requested to read and scrutinize adolescents’
medical records. Ratings, ranging from a minimum of
120 to a maximum of 168, were split into three groups:
120-132 (which we named as ‘opposition’), 133-145
(which we named as ‘ambivalent participation’), 146-
157 (which we named as ‘passive participation’) and
158-168 (which we named as ‘active participation’).
Rating was carried out by a neutral observer during the
clinical interviews. The type of intervention was de-
scribed on the basis of the single treatment or the asso-
ciation of different treatments as explained in the sample
Data about patients were collected in an anamnesis
schedule, then transferred into a computerised database
for computation, which is performed using SSPS version
10 and SAS® package, rel. 9.1.3.
Statistic Analysis: descriptive analysis, performed with
SSPS version 10, first included the frequencies distribu-
tion of the main variables collected in the study; then
since variables were all expressed in a nominal scale, a
Chi-squared test was carried out to identify the relation-
ships between therapeutic efficacy and other variables
referred to patients. A paired t-test was performed to
investigate the differences in YSR’s scores before and
after the intervention. Multivariate analysis, performed
with SAS® package, rel. 9.1.3, consisted in a multivari-
ate logistic regression to identify those variables related
to the therapeutic efficacy, while holding the other vari-
ables constant in the model. The value of p < 0.05 was
considered significant.
Among 112 adolescents who were referred in six
months time, 100 individuals had been clinically fol-
lowed for 12 months. They were 66 males and 34 fe-
males, aged between 12 and 19 years, affected by emo-
tional and behavioural problems. Their clinical files pro-
vided retrospective information about diagnostic and
M. Gatta et al. / HEALTH 2 (2010) 811-818
Copyright © 2010 SciRes. Openly accessible at http://www.scirp.org/journal/HEALTH/
therapeutic processes. The sample finally taken into
consideration was retrospectively divided into 5 groups
under therapeutic treatment:
1) psychological treatment
2) educational treatment
3) psychological and educational integrated treatment
4) psychiatric (pharmacological) and psychological
integrated treatment
5) psychological, psychiatric and educational integrated
Results about frequencies analysis of variables are rep-
resented in Tables 1-5.
Multivariate analysis (carried out with the SAS® pack-
age, rel. 9.1.3) was performed using a stepwise logistic
regression analysis (significance level for entering =
0.15 and significance level for removing = 0.10) to iden-
tify variables related to the therapeutic efficacy, which is
the depende nt di ch ot omous variable of the study .
Results of Logistic Regression Analysis for patients
with an efficient therapy result (cases) compared to pa-
tients with a not efficient treatment (controls) are repre-
sented in Table 4.
Patients with an adequa te therapeutic compliance have
a probability 5,762 times higher to present a clinical
improvement (p-value = 0.0076) co mpared with patients
Table 1. Observed distribution (frequencies and percentages)
by age inter vals and sex.
Freq %
12-14 yrs 43 43
15-17 yrs 46 46
18-19 yrs 11 11
Age intervals
Total 100 100
Male 66 66
Female 34 34
Total 100 100
Age categories by sex
Male Female Total
12-14 yrs 32 (74.4) 11 (25.6) 43 (100.0)
15-17 yrs 28 (60.9) 18 (39.1) 46 (100.0)
18-19 yrs 6 (54.5) 5 (45.5) 11 (100.0)
Table 2. Observed distribution (frequencies and percentages)
by diagnosis ICD 10 and type of treatment.
Freq %
Diagnosis ICD 10
Psychotic Disorders 18 18
Affective Syndroms 21 21
Neurotic Syndroms 10 10
Personality Disorders 21 21
Soft Mental Retardation 6 6
Behaviour/emotional Disorders 9 9
Eating disorders 4 4
Comorbility (personality dis. + anxiety
or mood dis.) 11 11
Total 100 100
Type of treatment
Educational Treatment 16 16
Psychological Treatment 15 15
Educational + Psychological Treatment 19 19
Psychological + Psychiatric Treatment 15 15
Educational + Psychiatric Treatment 7 7
Educational + Psychiatric + Psyc ho-
logical Treatment 28 28
Total 100 100
who are not compliant. A multiprofessional intervention
(p-value = 0.0242) and an active participation of the
patient during the treatment (p-value = 0,014) is associ-
ated with a probability more than four times higher to
obtain a clinical improvement. The last variable entered
in the model is ‘timing of therapy’ (p-value = 0.0163):
patients whose therapy lasts less than 3 months present a
very lower probability (OR = 0.062, CI = 0.009-0.439)
to get clinically better compared with patients whose
intervention lasts more than 9 months.
The p-value of likelihood ratio test < 0.0001 indicates
the efficiency of the final model. The percentages of
sensitivity and the specificity are respectively 86.2 % and
To analyse the differences in Achenbach’s scores
(means) before and after the intervention a paired t-test
was used. Table 5 shows there was a statistically signifi-
M. Gatta et al. / HEALTH 2 (2010) 811-818
Copyright © 2010 SciRes. Openly accessible at http://www.scirp.org/journal/HEALTH/
Table 3. observed distribution (frequencies and percentages)
by timing of intervention, patient’s participation, therapy eutic
Compliance and clinical outcome (GAF).
Freq %
Timing of intervention
< 3 months 19 19
3-9 months 41 41
> 9 months 40 40
Total 100 100
Patient’s participation
Active 53 53
Passive 17 17
Ambivalent 22 22
Total 100 100
Therapeutic compliance
Adequate 70 70
Discontinuous 20 20
Early interruption 10 10
Total 100 100
Clinical outcome (GAF) Freq %
Improved 58 58
Unchanged 31 31
Got worse 11 11
Total 100 100
cant change (p-value < 0.05) in patients’ Achenbach’s
mean scores, most probably due to the treatment efficacy.
It is evident, looking at the percentages, that normal
scores increased, whereas pathological ones significantly
Using the chi square test a statistically significant re-
sult about the relation between type of association of
treatments and clinical evolution was obtained: the pa-
tients who got clinically better are those who underwent
multiprofessional integrated therapy and in particular
association between psychological and educational in-
tervention, (63%), psychological and psychiatric inter-
vention (71%) and the three types together (79%).
The sample is formed by individuals, prevalently boys
(66%), basically aged between 12 to 17 years (Table 1).
According to literature which shows as in the child-
juvenile sectors of psych iatry, bo ys outnumber girls un til
the age of 12-14 years and then girls become the major-
ity [19], in our sample too the gap between genders de-
creases with age, so that after 17 years of age the per-
centage of males and females tends to become similar
(Table 1). Table 2 shows the diagnosis according to ICD
10 formulated at the end of the psychodiagnostic process.
The percentages are quite similar to those of literature
about epidemiology of psychiatric disorders in clinic
populations of adolescents and young adults [20-22].
The relevant percentage of severe psychopathology as
psychosis and personality disorder must be read also
within the typology of our service: a second level one
which in Italy means a structure functioning in between
a outpatients’ and inpatients’ service, where severe psy-
chiatric diseases are recovered and treated. Tables 2
shows types of intervention and treatments’ association:
the prevalence of multiprofessional interventions (asso-
ciation of three different therapies in 28% of cases), be-
sides being indicative again of the complexity of pa-
tients’ psychopathology, is linked to the general method-
ology of our Service where an approach to the adoles-
cent that integrates different therapeutic efforts (psychi-
atric, psychological and educational ones) is preferred
when possible to apply. About the timing of interven-
tions, Ta b l e 3 shows that most therapies last more than
three months (81%, and 40% more than nine months).
Those patients who underwent therapy for less than three
months usually are patients that dropped out. Actually,
being the Service one which receives individuals af-
fected by serious psycho-pathology, suggested therapies
habitually last 3 months at least. In Table 3 it is also
shown patient’s participation mode in the therapeutic
process: active, passive, oppositional or ambivalent. Pa-
tient’s way to participate during sessions and activities is
significant of the relationship with the therapist and
working on the therapeutic allian ce is very imp ortant for
a good compliance an d a positive outco me [23-25]. Data
about therapeutic compliance and clinical outcome (Ta-
ble 3) show that the most of adolescents (70%) followed
the therapeutic indicatio ns adequately and nearly 60% of
adolescents presented a clinical improvement one year
later. Results about outcome obtained using the GAF
(filled in by the operators) are confirmed by the ones
obtained using the YSR (filled in by the patients) (Table
5). Looking at the scores before and after the treatment it
can be noticed that there is an improvement for each
syndrome scale, with a statistically significant p-value <
M. Gatta et al. / HEALTH 2 (2010) 811-818
Copyright © 2010 SciRes. http://www.scirp.org/journal/HEALTH/Openly accessible at
0.05. There are no significant associations between di-
agnosis and outcome, suggesting that in developmental
age a clinical improvement is more dependent on the
therapy and the adherence to it, rather than on the spe-
cific psychopathology. Particularly, the results about
associations between compliance and outcome (patients
who undergo to therapy profiting of it) and between
therapy timing and outcome (the longer is the therapy,
the more probable is the improvement) suggest that the
intervention is efficient when the sessions are attended
continuously by the adolescent and for a longer time
(Table 4). A brief intervention (19% of adolescents came
to the centre for less than 3 months ) is strictly connected
with the phenomenon of drop out. This phenomenon
turns out to be more frequent at the beginning of the
treatment, and particularly in the first 3 months which is
the period dedicated to knowledge and definition of the
therapeutic project. The problem of early interruption is
significant for the relation with patients’ clinical out-
come. Between the adolescents who dropped out and
those who took part in the whole therapeutic project,
there is a statistically relevant difference in terms of
clinical evolution, respectively negative and positive.
Generally, it must be pointed out the statisticcally rele-
vant relation between therapeutic compliance and clini-
cal outcome: among patients who are compliant there is
a significantly larger rate of adolescents who have showed
clinical improvement, compared with the non compliant
adolescents. This data, moreover, confirms that patients
attending the Neuropsychiatric Unit are affected by a
psychological and behavioural disease which needs a
moderately long period of time to be worked out. On the
basis of this consideration it is possible to interpret the
result about the diagnosis (Table 2): such result, actu ally,
shows that most adolescents are affected by serious
psychiatric disorders (psychosis 18%, depression 21%
and personality disorders 21%). These psychopatho-
logical conditions are confirmed by the results of YSR:
looking at scores (borderline and clinic ones) before in-
tervention it can be noticed that the most frequent prob-
lems were: withdrawal and social problems (69% and
87%), anxiety and mood disorders (92%), attention
problems (97%) (Ta b l e 5 ). Attention problem is proba-
bly a symptom of anxious and depressive syndromes
rather than a symptom of an ADHD (Attention Deficit
and Hyperactivity Disorder). This is supported by the
fact that attention problems were reduced after interven-
tion (see YSR scores after intervention, Table 5) even if
the treatment was not specifically designed for ADHD
and the timing of therapy was not long enough for that
kind of disorder.
Our data suggests that an active participation of the
adolescent too contributes to the achievement of a posi-
tive result. Table 4, actually, shows that an active par-
ticipation of the patient during the treatment implies a
higher probability to obtain a clinical improvement. Ac-
cording to many authors this result confirms that with
adolescents, the therapeutic process must be supported
by patient’s motivation and his/her involvement into
therapy dynamics [ 26-29].
The association between type of intervention and out-
come shows that the subjects who got clinically betterare
those patients who underwent multiprofessional therapy
(Table 4) and, particularly, the associations between
psychological and educational intervention, (63%), psy-
chological and psychiatric intervention (71%) and the
three types together (79%). It must be pointed out that
these three types of multiprofessional intervention have
a common element that is the focus on the human rela-
tionship: that is the relation between the patient and the
clinician/therapist or with the educational professional.
Moreover, these types of interventions require an inter-
professional team to integrate different therapeutic ac-
tions applied to the same patients. Both a multiprofes-
sional intervention (giving a specific answer to the indi-
vidual and a answer thanks to the intervention of differ-
Ta ble 4. Results of logistic regression analysis for patients with therapy effectiveness (cases) compared to patients without therapy
effectiveness (controls).
Maximum likelihood
estimate Standard Errorp-value Odds ratio 95%CI
Therapeutic compliance (ref. ‘adequate’) 1.751 0.656 0.0076 5.762 1.594-20.829
Type of intervention (ref. ‘multiprofessional’) 1.432 0.635 0.0242 4.187 1.205-14.544
Timing of intervention (‘< 3 months’ compated to
‘> 9 months’) -1.483 0.617 0.0163 0.062 0.009-0.439
Patient’s participation to the therapy (ref. ‘active’) 1.468 0.597 0.014 4.342 1.346-14.002
Likelihood ratio test: p < 0.0001. Ref, reference category; CI, confidence intervals.
M. Gatta et al. / HEALTH 2 (2010) 811-818
Copyright © 2010 SciRes. Openly accessible at http://www.scirp.org/journal/HEALTH/
Table 5. Distribution of patients by Achenbach’s scores before and after the intervention [observed frequencies (%)] and paired t-test
value with corresponding p-value.
before (100 patients)after (94 patients) paired t-test value p-value
normal 31 (31) 66 (70.2)
borderline 21 (21) 19 (20.2)
clinic 48 (48) 9 (9.6)
5.61 < 0.0001
normal 41 (41) 67 (71.3)
borderline 40 (40) 25 (26.6) Somatic complaints
clinic 19 (19) 2 (2.1)
5.03 < 0.0001
normal 8 (8) 41 (43.6)
borderline 31 (31) 50 (53.2)
Anxious-depressive problems
clinic 61 (61) 3 (3.2)
9.79 < 0.0001
normal 13 (13) 45 (47.9)
borderline 41 (41) 41 (43.6) Social problems
clinic 46 (46) 8 (8.5)
6.43 < 0.0001
normal 40 (40) 64 (68.1)
borderline 35 (35) 23 (24.5)
Thought problem s
clinic 25 (25) 7 (7.4)
3.54 < 0.001
normal 30 (30) 65 (69.1)
borderline 46 (46) 27 (28.7) Problems of Attention
clinic 24 (24) 2 (2.1)
6.45 < 0.0001
normal 80 (80) 84 (89.4)
borderline 14 (14) 9 (9.6)
Delinquent behaviour
clinic 6 (6) 1 (1.1)
2.49 < 0.05
normal 54 (54) 75 (79.8)
borderline 27 (27) 17 (18.1) Aggressive behaviour
clinic 19 (19) 2 (2.1)
4.58 < 0.0001
ent professionals) and a shared methodology with the
possibility of verifying the work done on the individual
within a group, contribute to a positive outcome [30,31].
According to that, many studies have just tested the effi-
ciency of multimodal interventions on different psycho-
pathologies such as ADHD, anxiety disorders, suicidal
behaviours, conduct disorders, psychosis etc. [32-35].
This study, with the limitation of being a retrospective
research, confirms the major efficacy of a multiprofes-
sional integrated approach to the adolescent’s psychopa-
thology in comparison with approaches based on a single
therapeutic interven tion.
A rigid separation among approaches could actually
make the operator run the risk of getting a deformed
vision of patient’s real needs. This approach does not
consider the patient as a complex whole and could easily
lead to partial and inefficient interventions.
In order to obtain a positive clinical outcome in the
treatment of young patients affected by psychiatric dis-
M. Gatta et al. / HEALTH 2 (2010) 811-818
Copyright © 2010 SciRes. Openly accessible at http://www.scirp.org/journal/HEALTH/
ease, it is essential to organize services for adolescents
trying to stimulate and support team work, so as to as-
sure a multiprofessional intervention.
[1] Bachmann, M., Bachmann, C., Rief, W. and Mattejat, F.
(2008) Efficacy of psychiatric and psychotherapeutic in-
terventions in children and adolescents with psychiatric
disorders—A systematic evaluation of meta-analyses and
reviews. Part II: ADHD and conduct disorders. Z Kinder
Jugendpsychiatr Psychother, 36(5), 321-333.
[2] Bachmann, M., Bachmann, C., Rief, W. and Mattejat, F.
(2008) Efficacy of psychiatric and psychotherapeutic in-
terventions in children and adolescents with psychiatric
disorders-a systematic evaluation of meta-analyses and
reviews. Part I: Anxiety disorders and depressive disor-
ders. Z Kinder Jugendpsychiatr Psychother, 36(5), 309-
[3] Velligan, D.I., Draper, M., Stutes, D., Maples, N., Mintz,
J., Tai, S. and Turkington, D. (2009) Multimodal Cogni-
tive Therapy: Combining Treatments That Bypass Cog-
nitive Deficits and Deal With Reasoning and Appraisal
Biases. Schizophrenia Bulletin, 35(5), 884-893.
[4] MTA Cooperative Group National Institute of Mental
Health (2004) Multimodal Treatment Study of ADHD
Follow-up: 24-Month Outcomes of Treatment Strategies
for Attention-Deficit/Hyperactivity Disorder. Pediatrics,
113(4), 754-761.
[5] Connor, D.F., Carlson, G.A., Chang, K.D., Daniolos, P.T.,
Ferziger, R., Findling, R.L., Hutchinson, J.G., Malone,
R.P., Halperin, J.M., Plattner, B., Post, R.M., Reynolds,
D.L., Rogers, K.M., Saxena, K., Steiner, H., Stan-
ford/Howard/AACAP Workgroup on Juvenile Impulsiv-
ity and Aggression (2006) Juvenile maladaptive aggres-
sion: a review of prevention, treatment, and service con-
figuration and a proposed research agenda. Journal of
Clinical Psychiatry, 67(5), 808-820.
[6] Masi, G., Milone, A., Manfredi, A., Pari, C., Paziente, A.
and Millepiedi, S. (2008) Conduct disorder in referred
children and adolescents: Clinical and therapeutic issues.
Comprehensive Psychiatry, 49(2), 146-153.
[7] Herpertz-Dahlmann, B. and Salbach-Andrae, H. (2009)
Over-view of treatment modalities in adolescent anorexia
nervosa. Child and Adolescent Psychiatric Clinics of
North America, 18(1), 131-145.
[8] Steiner, H. and Remsing, L. (2007) Work Group on
Quality Issues Practice parameter for the assessment and
treatment of children and adolescents with oppositional
defiant disorder. Journal of the American Academy of
Child and Adolescent Psychiatry, 46(1), 126-141.
[9] Nützel, J., Schmid, M., Goldbeck, L., Fegert, J.M. (2005)
Psychiatric support for children and adolescents in resi-
dential care in a German sample. Praxis der Kinder-
psychologie und Kinderpsychiatrie, 54(8), 627-644.
[10] World Health Organization (1992) The ICD-10 Class-
ification of Mental and Behavioural Disorders: Clinical
Descriptions and Diagnostic Guidelines. WHO, Geneva.
[11] American Psychiatric Association (1994) Diagnostic and
Statistical Manual of Mental Disorders, Axis V. American
Psychiatric Associat ion, W ashin gton, D.C.
[12] Startup, M., Jackson, M.C., Bendix, S. (2002) The
concurrent validity of the Global Assessment of Fun-
ctioning (GAF). British Journal of Clinical Psychology,
41(4), 417-422.
[13] Achenbach, T.M., Rescorla, L.A. (2001) Manual for the
ASEBA School Age-Forms & Profiles. University of
Vermont, Research Center for Children, Burlington.
[14] Ivanova, M.Y., Achenbach, T.M., Rescorla, L.A., Du-
menci, L., Almqvi st, F., Bile nberg, N., Bird, H., Broberg,
A.G., Dobrean, A., Döpfner, M., Erol, N., Forns, M.,
Hannesdottir, H., Kanbayashi, Y., Lambert, M.C., Leung,
P., Minaei, A., Mulatu, M.S., Novik, T., Oh, K.J., Rous-
sos, A., Sawyer, M., Simsek, Z., Steinhausen, H.C.,
Weintraub, S., Winkler Metzke, C., Wolanczyk, T., Zilber,
N., Zukauskiene, R. and Verhulst, F.C. (2007) The gener-
alizability of the Youth Self-Report syndrome structure in
23 societies. Journal of Consulting and Clinical Psy-
chology, 75(5), 729-738.
[15] Ivanova, M.Y., Dobrean, A., Dopfner, M., Erol, N.,
Fombonne, E., Fonseca, A.C., Frigerio, A., Grietens, H.,
Hannesdottir, H., Kanbayashi, Y., Lambert, M., Achenr-
bach, T.M., Larsson, B., Leung, P., Liu, X., Minaei, A.,
Mulatu, M.S., Novik, T.S., Oh, K.J., Roussos, A., Saw-
yer, M., Simsek, Z., Dumenci, L., Steinhausen, H.C.,
Metzke, C.W., Wolanczyk, T., Yang, H.J., Zilber, N., Zu-
kauskiene, R., Verhulst, F.C., Rescorla, L.A., Alm-qvist,
F., Weintraub, S., Bilenberg, N., Bird, H. and Chen, W.J.
(2007) Testing the 8 syndrome structure of the CBCL in
30 societies. Journal of Clinical Child and Adolescent
Psychology, 36(3), 405-417.
[16] Horvath, A.O. and Greenberg, L.S. (1989) Development
and validation of the working alliance inventory. Journal
of Counseling Psychology, 36(2), 223-233.
[17] Di Giuseppe, R., Linscott, J. and Jilton, R. (1996) De-
veloping the therapeutic alliance in children-adolescent
psychotherapy. Applied & Preventive Psychology, 5(2),
[18] Lingiardi, V. (2002) L'alleanza terapeutica. Teoria,
clinica, ri cerca. Cortina Raffaello, Mi la no.
[19] Cohen, P., Cohen, J., Kasen, S., Velez, C.N., Hartmark,
C., Johnson, J., Rojas, M., Brook, J. and Streuning, E.L.
(1993) An epidemiological study of disorders in late
childhood and adolescence-I. Age- and gender-specific
prevalence. Journal of Child Psychology and Psychiatry,
34(6), 851-867.
[20] Costello, E.J., Foley, D. and Angold, A. (2006) 10-Year
Research Update Review: The Epidemiology of Child
and Adolescent Psychiatric Disorders: II. Developmental
Epidemiology. Journal of the American Academy of Child
& Adolescent Psychia try , 45(1), 8-25.
[21] Gabbard, G.O. (2000) Psychodynamic Psychiatry in
Clinical Practice, 3rd Edition. American Psychiatric
Press, Washington, D.C.
[22] Donald, W., Spady, M.D., Donald, P., Schopflocher,
Lawrence, W., Svenson, B., Angus and H., Thompson.
(2001) Prevalence of mental disorders in children living
in Alberta, Canada, as determined from physician billing
data. Archives of Pediatrics & Adolescent Medicine, 155,
[23] Horvath, A.O. and Symonds, B.D. (1991) Relation be-
M. Gatta et al. / HEALTH 2 (2010) 811-818
Copyright © 2010 SciRes. http://www.scirp.org/journal/HEALTH/Openly accessible at
tween working alliance and outcome in psychotherapy: A
meta-analysis. Journal of Counselling Psychology, 38(2),
[24] Luborsky, L. (2000) A pattern-setting therapeutic alli-
ance study revisited: helping alliances in psychotherapy.
Psychotherapy Re s e a rch, 10, 17-29.
[25] Martin, D.J., Garske, J.P., Davis, M.K. (2000) Relation of
the therapeutic alliance with outcome and other varia-
bles: A meta-analytic review. Journal of Consulting and
Clinical Psycho l o g y, 68(3), 438-450.
[26] Horvath, A.O. and Luborsky, L. (1993) The role of thera-
peutic alliance in psychotherapy. Journal of Consulting
and Clinical Psychology, 61(4), 561-573.
[27] Marcelli, D. and Braconnier, A. (1995) Adolescence et
Psychopathologie. Masson, Paris.
[28] Laufer, M. (1997) Adolescent Breakdown and Beyond.
Karnak Books, London.
[29] Hintikka, U., Laukkanen, E., Marttunen, M. and Lehto-
nen, J. (2006) Good working alliance and psychotherapy
are associated with positive changes in cognitive perfor-
mance among adolescent psychiatric inpatients. Bulletin
of the Menninger Clinic, 70, 316-335.
[30] Wachtel, P.L. (1977) Psychoanalysis and behaviour ther-
apy: Toward an integration. Guilford Press, New York.
[31] Kaneklin, C. and Orsenigo, A. (1992) Il lavoro di
Comunità. Nuova Italia Scientifica, Roma.
[32] Rea, M., Braccini, L., Laviola, G., Ferri, R. (2006) ADHD
and multimodal intervention. Annali dell' Istituto Super-
iore di Sanità, 42(2), 231-245.
[33] Russell, P.S., Raj, S.E., John, J.K. (1998) Multimodal
intervention for selective mutism in mentally retarded
children. Journal of the American Academy of Child and
Adolescent Psyc h iatry, 37(9), 903-904.
[34] Henggeler, S.W., Schoenwald, S.K., Borduin, C.M.,
Rowland, M.D. and Cunningham, P.B. (1998) Multi-sys-
temic treatment of antisocial behaviour in children and
adolescents. Guilford Press, New York.
[35] Clark, A.F. (2001) Proposed treatment for adolescent
psychosis. Schizophrenia and schizophrenia-like psyc-
hoses. Advances in Psychiatri c Treatment, 7, 16-23.