Adolescent Psychiatric Services Research Articles

Services for adults with autism spectrum disorders

Psychiatry in the United Kingdom has overhauled its approach to the provision of services for adults with autism spectrum disorders (ASD). This shift is set out in a new policy document, Psychiatric Services for Adolescents and Adults with Asperger's Syndrome and other Autistic‐spectrum Disorders (Royal College of Psychiatrists, 2005).

Transparent criteria for specialist level adolescent psychiatric care

Rising health care costs and long waiting lists pose a challenge to public specialist level health services. In Finland, the Ministry of Social Affairs and Health required all medical specialities to create a priority-rating tool for elective patients, preferably giving a numerical rating ranging 0-100, with 50 as an entry threshold. To create and test the psychometric properties of a point-count measure for prioritising entry to public specialist level adolescent psychiatric services. Around 710 referred adolescents were given ratings on 17 items focusing on symptom severity, problem behaviours, functioning, progress of adolescent development and prognosis. The structured ratings were compared to an overall assessment of need for treatment on a VAS scale. In order to ensure that the tool was not inappropriately sensitive to confounding by non-disturbance related factors, the associations between the structured priority rating and sex, age, referring agent, study site and diagnosis were analysed. Of the 17 items, 15 were included in the final priority-rating tool. The requirement than threshold score for entry to services being set at 50 points necessitated scoring factors rather than individual items. Four blocks of items were formed: symptoms and risks; impaired functioning; other relevant issues, and prognosis without specialist level treatment. Most of the referred adolescents scored over the threshold of 50. When diagnosis was controlled for, scoring over 50 was largely independent of age, sex, referring agent or study site. The structured priority ratings corresponded well with clinical global rating of need for care. The tool was not inappropriately sensitive to age, sex, referring agent or study site. In the future, follow-up studies will be needed to evaluate the predictive value of priority ratings.

Eine Universitätsklinik als psychiatrisches Versorgungszentrum für Kinder und Jugendliche

The article reports on a system of care for psychiatrically ill children and adolescents that has been designed, established and expanded since 1980 by a university department in a rural region. The department is responsible for the mental health care of three counties with altogether 807 000 inhabitants. The development of this system of care was due in great part to the model program of the German Federal Government for the reform of mental health care that comprised 14 model regions, out of which the region of Marburg and its surrounding counties was the only one with a focus on the situation of psychiatrically ill children and adolescents. With the aid of this model program, a comprehensive evaluation of existing psychiatric services was carried out and at the same time, new services for this clientele were established such as a mobile child and adolescent psychiatric service and a day hospital. A particular focus was laid on the development of a complete network of psychiatric services with manifold, and over the years well proven, cooperation measures. Finally, the quality of mental health care was significantly increased by a continuous evaluation of services and the implementation of two institutes for psychotherapeutic training. Several research initiatives in the field of social psychiatry have contributed to this amelioration and at the same time, to a successful integration of mental health care and research.

Is bipolar II disorder misdiagnosed as major depressive disorder in children?

Objectives: To estimate the lifetime prevalence of bipolar II disorder in children and adolescents presenting with DSM-IV major depressive disorder (MDD). Methods: Sixty-one consecutive subjects aged ≤ 18 years attending the outpatient services of the Child and Adolescent Psychiatric (CAP) services of the National Institute of Mental Health and Neurosciences (NIMHANS), Bangalore, India with a diagnosis of MDD were evaluated using the Missouri Assessment of Genetics Interview for children (MAGIC). Two psychiatrists, one of whom was a child psychiatrist diagnosed hypomania by consensus. Results: Twelve children had a past episode of hypomania (20%), which was hitherto undiagnosed clinically. Limitations: We recruited subjects from a psychiatric hospital, thus limiting the generalizability of the finding. Sample size was relatively small and assessments were cross-sectional. Conclusions: Our study shows that bipolar II disorder is often misdiagnosed as MDD in children. The study also highlights that the chance of diagnosing bipolarity is enhanced by using semi-structured interview in routine clinical practice.

Psychiatric Services for Adolescents and Adults with Asperger Syndrome and Other Autistic-Spectrum Disorders

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Special-needs student’s psychiatric treatment chain:

Objectives. The problems of children and adolescents have increased innumber and severity during the last years. The purpose of the study was toexplore the need for, and the utilisation and functionality of, the specializedpsychiatric health care services available to children and adolescentsof comprehensive and senior secondary school age. The main object ofthe study was to describe a special-needs pupil’s psychiatric pathway ofcare, and to evaluate its functionality and the need for multi-professionalco-operation from the perspective of the networked experts and clients.Study design. Qualitative study employing data and methodological triangulation, questionnaires, multiple constituency evaluations and content analysis.Methods. Data were collected from 112 (82 %) comprehensive schools and senior secondary schools, with a total of 18,532 students, in Oulu Province, Finland, during the period 1998 – 2002. Thirty-seven (97 %) special schools had a total of 1276 students. The data for the first and second sub-studies were collected with a questionnaire. The data for the third sub-study were obtained from documents concerning the need for, and the use and functionality of services provided and evaluated by the key groups of actors. The data sets were evaluated using the multiple constituency methods in co-operative evaluation sessions, which were video-taped. The data for the fourth sub-study consisted of tape-recorded interviews of the study subjects. The phenomenon under study was approached from a number of evaluative perspectives, and data and methodological triangulation was used. Multiple constituency evaluation and content analysis were used as research methods.Results. As evaluated by comprehensive school and senior secondary school teachers, both the incidence and the severity of students’ conduct and emotional disorders have increased over the past few years. Special school students with conduct disorders and mental health problems were referred for examinations and treatment into the treatment chain of child and adolescent psychiatry similarly to other school-aged children and adolescents. Special schools had a constant need for child and adolescent psychiatric services, but there were no direct connections with specialized health care. At all schools, efforts were made by teachers and parents to help students with the assistance of school health care and social work professionals. Whenever students failed to get the requisite help from specialized health care, their problems remained the family’s responsibility. The parents in these situations felt that they had been left alone, without understanding what it was all about and without knowing where to go for help. Nevertheless, the data also included many positive experiences of fluent co-operation and easy availability of help for the student. The findings showed that there is a lot of expertise and a sincere desire to work for the benefit of children and adolescents. The lack of coordination of the entire treatment chain did, however, wear down the self-esteem of the students in need of help, as well as the meagre resources of their parents and the help-providing key actors. All stages of research highlighted the evident need for closer co-operation between the key groups of the network responsible for the treatment chain and the need for social work and health care liaison persons, who could be contacted quickly. It was also suggested that the key groups participating in the treatment chain should be provided joint training and mentoring. The outreach outpatient clinic coordinated by the Clinic of Child Psychiatry was considered extremely important, because it provided specialized expertise locally at the municipal level.Conclusions. The major problems in the functionality of the psychiatric treatment chain were the availability of services and the flow of information. The pupils’ coping was impaired by their crumbling self-esteem and the slow provision of help. In spite of the legislation, the rehabilitation of special-need pupils and the collaboration between schools and mental health authorities are not optimal.

Telepsychiatry for Treating Rural American Indian Youth

Of all of the medical specialties, child and adolescent psychiatry has the most severe shortage of practitioners. This shortage is even more pronounced in economically disadvantaged and rural areas (Clark et al., 1999; Pollitt, 2000; Satcher, 1999). The American Indian population is younger, more economically disadvantaged, and more rural than the general U.S. population (United States Census Bureau, 2000). Researchers and many American Indians believe that their traumatic history and current marginalization has made them more likely to experience mental health problems such as alcoholism and posttraumatic stress disorder (Beals et al., 2003, 2005; Spicer et al., 2003). The Surgeon General has made it a priority to improve mental health services, especially for children and adolescents (Satcher, 1999). American Indians should not be left out of this movement. Telepsychiatry, the use of real-time, interactive videoconferencing to deliver psychiatric services, is an exciting opportunity to ensure that they are not. There have been approximately 30 articles and papers regarding the use of telepsychiatry services to provide mental health services to children and adolescents (Pesamaa et al., 2004). This includes two randomized, controlled trials. One of these trials showed that diagnoses and treatment recommendations made by child psychiatrists by telemedicine and in faceto-face interviews were similar 96% of the time (Elford et al., 2000). The other showed that psychotherapeutic treatment of depressed children via telemedicine can be effective (Nelson, et al., 2003). The remaining studies are primarily descriptive and offer case examples or case series. These articles report that patients and providers were satisfied with the services offered and results obtained (Blackmon et al., 1997; Elford et al., 2000; Ermer, 1999a,b; Hilty et al., 2000; Miller et al., 2002). Although some clinicians expressed concern that it was more difficult for patients to convey emotions to providers via telepsychiatry, they concluded that their ability to provide effective, high-quality services was not significantly impaired by this. Furthermore, some clinicians have observed that the distance from the provider seemed to make it easier for some patients to relate sensitive information that could be important in treatment. The authors of these articles concluded that use of telepsychiatry can assist in providing child and adolescent psychiatric services to patients in remote and underserved areas while sparing patients and providers long, expensive, and life-disrupting journeys. One can expect that American Indians, a group that has been subjected to considerable trauma by the U.S. government, may be suspicious of initiatives by the government to try to help them. In fact, many American Indians have expressed distrust of the Indian Health Service (IHS) precisely because most of the providers are not Indian, come from outside communities, and often stay at their posts only long enough to complete their several-year commitments (Allen et al., 2004; Novins et al., 2004). Many American Indians have participated in research projects but have not Accepted September 1, 2005. Drs. Savin and Garry are with the Department of Psychiatry, University of Colorado Health Sciences Center, Denver; Dr. Garry and Ms. Zuccaro are with Rapid City Indian Health Service Hospital, Rapid City, SD; Dr. Novins is with the Division of American Indian and Alaska Native Programs, Department of Psychiatry, University of Colorado Health Sciences Center, Denver. This project was supported by grants from the National Center for Minority Health and Health Disparities (MD000507, Spero Manson, Ph.D., PI) and the Agency for Healthcare Research and Quality (HS10854, Spero Manson, Ph.D., PI). Correspondence to Dr. Daniel Savin, Department of Psychiatry, University of Colorado Health Sciences Center, University North Pavilion, Box A011-15, 4455 East 12th Avenue, Denver, CO 80220; e-mail: daniel.savin@uchsc.edu. 0890-8567/06/4504Y0484 2006 by the American Academy of Child and Adolescent Psychiatry. DOI: 10.1097/01.chi.0000198594.68820.59 C L I N I C A L P E R S P E C T I V E S Associate Editor: Michael S. Jellinek, M.D.

Telepsychiatry in a Child and Adolescent Psychiatric Service

To carry out a survey on the use of video conferencing equipment by a rural child psychiatric multidisciplinary team and to determine what impact the introduction of this equipment had on service provision. Several aspects were studied including user satisfaction and estimations of cost saving, on the basis of avoidance of travel to and from the regional base in Galway. A questionnaire was also developed to determine whether alternative contact would have been made if if this new technology were not in place. The results of the initial six months following commencement were investigated. Use of the equipment was attempted 17 times during this period. Most members of the child psychiatry team participated in its use. Visual problems accounted for 66.7% of reported technical difficulty and 88.9% of users rated their level of satisfaction with the equipment as 'Satisfied' or 'Very Satisfied'. Apart from the start-up cost implications of installing this equipment, it satisfied its aim of increasing contact between the rural service and St Anne's Children Centre in Galway. The equipment was easy to use and for the most part reliable.

Mental health services provided for physically abused children in Sweden. A 4-year follow-up of child and adolescent psychiatric charts

As there has been a considerable increase regarding the number of police reports on physical child abuse in Sweden since the mid-1980s, there should be an increased number of children in need of trauma-focused mental health treatment. During 1986–1996, there were 126 children reported as being physically abused by a parent or equivalent and reported to the police in a police district in Sweden. Fifty-seven of these children (45%) had been the objects of interventions from Child and Adolescent Psychiatric Services (CAPS). The aim of this study was to investigate the extent and content of this. Questions addressed were: when did the children receive interventions, were these trauma-focused and could this be reflected in their charts? This group of children was referred to CAPS for different reasons and 35/122 referrals were made under the label of child physical abuse. Overall, interventions were mainly directed toward the parents. Six of 126 physically abused children received individual therapy. Abuse was not mentioned in the charts for 23 of the children, even though eight of them had been referred due to abuse. The results of this study indicate that physically abused children have often been in contact with mental health services prior to the abuse for different reasons, initially due to individual problems and later on regarding family conflict. Individual interventions for physically abused children were rare due to for instance CAPS workloads, poor motivation among parents and children, and maybe due to professionals’ lack of knowledge regarding effective treatment. The introduction of a routine checklist is recommended early on to find indications of abuse, as is the need of exploring methods working with physically abused children in Sweden.

Chemical Dependency and Psychiatric Services for Adolescents in Private Managed Care: Implications for Outcomes

Many adolescents with alcohol and drug problems have mental health comorbidities. The literature suggests that patients entering chemical dependency (CD) treatment with co-occurring problems have less successful outcomes, including treatment dropout and relapse. We examined the impact of psychiatric services on treatment initiation, retention, and alcohol and drug abstinence outcomes for adolescents in CD treatment. Participants were 419 adolescents aged 12-18 years who were seeking treatment at four CD programs of a nonprofit, managed care, group model health system and a parent or guardian for each adolescent. We surveyed participants at intake and 6 months and examined clinical and administrative data on diagnoses and CD and psychiatric utilization. Six-month response rates were 91% for adolescents and 93% for parents. Fifty-five percent of the patients with treatment intakes had at least one psychiatric diagnosis in addition to a substance use disorder. Compared with matched controls, patients with CD intakes had higher rates of depression, anxiety, eating disorders, attention deficit hyperactivity disorder, conduct disorder, and conduct disorder including oppositional defiant disorder. Thirty-one percent of the full sample had psychiatric visits in the 6 months after intake; among those with a psychiatric diagnosis, 54% had a psychiatric visit. Girls and those with higher Youth Self-Report internalizing scores were more likely to have a psychiatric visit (OR = 2.27, p < 0.001 and OR = 1.05, p < 0.0001, respectively). Adolescents receiving psychiatric services were more likely to be abstinent from both alcohol and drugs than those not receiving these services (OR = 1.57, 95% CI = 0.98-2.5) and more likely to be alcohol abstinent (OR = 1.68, 95% CI = 1.00-2.85). Those adolescents at colocated clinics had higher odds of abstinence from both alcohol and drugs (OR = 1.57, 95% CI = 1.03-2.39) and drugs (OR = 1.84, 95% CI = 1.87-2.85) and of returning after intake to initiate CD treatment (OR = 2.28, 95% CI = 1.44-3.61, p < 0.001) than others. Our results demonstrate the need for psychiatric treatment of adolescents in CD treatment and highlight the importance of their receiving such services.

Social services provided for physically abused children in Sweden: background factors and interventions

This study aims at describing and analysing what kinds of social services are provided for physically abused children in Sweden. The social services files were examined for 113 children under 15 years of age (67 boys and 46 girls) who had been reported to the police as having been physically abused by a parent or equivalent caretaker in a particular police district. The children's social services files indicated an increased risk of a parental abusive behaviour prior to the abuse incident. There had been former interventions in 81 per cent of the families and previous reports on neglect or abuse in 44 per cent of the 113 families. After the abuse incident, investiga‐tions were opened in 80 per cent of the cases. The three most common interventions were placement in foster care, referrals to Child and Adolescent Psychiatric Service and Social Services support contacts. The study shows that there was a tendency towards more proactive work with injured children, children of immigrant parents and children of mentally ill parents.

Changes in referrals to child and adolescent psychiatric services in Norway 1992–2001

The study analyzes changes in types of problems referred to child and adolescent psychiatry in Norway from 1992 to 2001, and investigates if referral practices and media attention account for these changes. All referrals to child and adolescent psychiatry in Norway in the period 1992--2001 were analyzed, as well as frequencies of articles in media on psychiatric problems. The shares of referrals for sadness/depression increased from 0.5 % to 15.4 %. Referrals for hyperactivity/attention problems increased from 1.2 % to 13.6 %. The increases could be statistically attributed to decreased use of other referral categories, and/or alternatively to media attention on these and related topics. Convergence between diagnosis and corresponding referral problem increased in the period. Referrals for sadness/depression and hyperactivity/attention problems increased sharply in Norway during the 1990s. This increase may be attributed to a different understanding of and a sharper look at these problems by referral agencies and by increased media attention.

Psychiatric treatment and research unit for adolescent intensive care: the first adolescent forensic psychiatric service in Finland.

Finland does not have a history of providing forensic adolescent psychiatric units although the need for this kind of service has been established. According to legislation patients who are minors have to be treated separately from adults, however, this has not been possible in practice. Also, adolescent psychiatric wards have not always been able to admit the most severely ill patients, those with impulsive and aggressive behaviours, because of lack of staff resources, problems associated with protecting other vulnerable patients and a shortage of secure environments. A previous report demonstrated the significant increase in adolescent's involuntary treatment within adult psychiatric wards. Data from this report were acknowledged as an important starting point in the planning process for the psychiatric treatment and research unit for adolescent intensive care. This paper describes the background, development process, plan of action, tailor-made education programme and supporting evidence for the first Finnish adolescent forensic service opened in April 2003 in the Department of Psychiatry, Tampere University Hospital. The tool used for planning the unit's activities and staff education programme was the Balanced Score Card approach, the structure and development of which is also outlined within the paper.

Lorenz Curves: A New Model for the Distribution of Psychiatric Services

The growth of child and adolescent psychiatric services based on the wraparound philosophy raises new questions for medical directors, investigators, and clinicians interested in improving quality of care and outcomes. Typically, quality improvement studies have focused on standardizing care and decreasing variation while community based services following a wraparound model are by definition individualized. To date, little information on how to evaluate such services in a managed care environment has been available. We present one option for evaluating the distribution of medical services and the extent to which providers individualize services for children with severe emotional disorders. Specifically, we (a) review the philosophy and goals of wraparound services, (b) introduce the Lorenz curve as a tool for determining the degree of inequality in service distribution at a given institution, and (c) present a case study on the use of Lorenz curves by a Medicaid Behavioral Health Organization in profiling behavioral providers.

Substance misuse among young people referred to a UK psychiatric servicemxSubstance misuse among young people referred to a UK psychiatric service.

Although substance misuse by adolescents is widespread, few previous studies have investigated illicit drug use in adolescent psychiatric populations. The literature on adolescent substance misuse has focused on risk factors, and protective factors have received little or no attention. The study examined substance misuse and its correlates among young people referred to a regional adolescent psychiatric service. Co‐morbidity of substance misuse and psychiatric disorder was discussed, and the possible role of substance misuse as a gateway to adolescent offending examined. Recommendations for the development of adolescent substance misuse services are made.

Stability within the Chaos: The Koori Kids Mental Health Network

Introduction: The Koori (Aboriginal term for Indigenous people from South Eastern Australia) Kids Mental Health Network is a child, adolescent and family psychiatric service based at the Victorian Aboriginal Health Service, a community health service which is controlled by the Victorian Koori community and based in Melbourne. The Koori Kids Mental Health Network is a collaborating group of Indigenous mental health workers from the Victorian Aboriginal Health Service and other health services together with a network of non-Indigenous workers from mainstream child and adolescent mental health services.Method: This article is a distillation of a 3-hour workshop involving seven members of the Koori Kids Mental Health Network. It comprised an introduction regarding the development of the Network, a section on the process by which Indigenous and mainstream workers have developed their working relationships and fostered each other's development according to the needs of Indigenous families, and a section on the ...

A new priority in psychiatry: Focused services for adolescents

Finland was the first European country to give a high priority to the development of specialized psychiatric services for adolescents. The aim of this paper is to 1) describe the development of these services, 2) study the status and the functioning of psychiatric services for adolescents in 2000 and 3) present some future challenges. The data have been collected from the social welfare register, from a questionnaire sent to Health Districts and via telephone interviews. In addition, the functioning of the treatment system has been studied in detail in one Health District by means of interviews and questionnaires. The general targets set in 1987 giving national priority to focused psychiatric services for adolescents were mostly reached in 2000, and resources for adolescents have increased markedly. In spite of this, minors still have to be treated in adult psychiatric wards. Many problems were detected in the functioning of the chains of treatment for adolescents. The differentiation between primary and secondary care was unclear. Primary care had a limited capacity in the early detection of mental disorders in adolescents. The services for adolescents were broken down into small units. Furthermore, there were no comprehensive future plans. The need for specialized psychiatric services for adolescents is evident. In addition to developing adequate resources, the quality of care should also be guaranteed by training and by competent long-term planning of psychiatric service systems.

Emergency presentations to an inner-city adolescent psychiatric service

There is little research into emergency presentations in child and adolescent mental health. The purpose of this study was to obtain an overview of number and types of presentations to a inner London child and adolescent mental health emergency service and to determine immediate and longer-term service demands. All available data on 107 consecutive child and adolescent emergency attenders were gathered using a structured data collection sheet. Half of those who presented following an episode of deliberate self-harm were considered to have no mental health disorder though a significant minority of emergency attenders had serious mental health problems. Most attenders were already known to child psychiatry or social services. Prospective study of young people who are already linked in with child mental health and/or social services but who require emergency assessments and interventions is warranted. An understanding of what breaks down in the routine care of these young people would facilitate earlier identification and more effective prevention or early intervention for these vulnerable children and adolescents. Copyright 2002 The Association for Professionals in Services for Adolescents. Published by Elsevier Science Ltd. All rights reserved.

In-Patient Admission of Adolescents with Mental Disorder

Whilst all developed countries report high rates of adolescent mental disorder, there has been a decline in adolescent in-patient provision in the UK in recent years. This report shows that only 0.3% of adolescents requiring psychiatric admission in the North West of England were admitted to an adolescent psychiatric unit, the rest being treated in adult mental health or non-psychiatric facilities. These findings point to a considerable need for and under-provision of adolescent psychiatric services, including in-patient beds, in North West England. This situation probably exists elsewhere in the UK, where development of adolescent and youth services has lagged behind Europe and North America.

Lithium reduced aggression and was safe in aggressive children and adolescents with conduct disorder admitted to hospital

Malone RP, Delaney MA, Luebbert JF, et al. A double-blind placebo-controlled study of lithium in hospitalized aggressive children and adolescents with conduct disorder. Arch Gen Psychiatry2000 Jul; 57 : 649...