Child Psychiatry Services Research Articles

Çocuk ve ergen psikiyatrisi polikliniğine başvuran hastalarda tanı dağılımı / Diagnoses of patients referring to a child and adolescent psychiatry outpatient clinic

Diagnoses of patients referring to a child and adolescent psychiatry outpatient clinic Objective: The aim of the present study is to identify the diagnoses of patients who referred to a child and adolescent psychiatry outpatient clinic. Method: Medical records of 538 patients referred to the Children and Adolescent Psychiatry outpatient clinic at Gulhane Military Medical School, between January 2009 and June 2009 were studied retrospectively. Results: It was found that the patients were mostly male and within 7 to 18 years of age. It was also determined that three quarters of patients had at least one diagnosis and the diagnosis rate in children between the ages of 0-6 was 50 percent. Comorbid diagnoses were found in 13.7 percent of all cases and they were mainly in the attention deficit hyperactivity disorder (ADHD) group. The most common diagnoses were ADHD, generalized anxiety disorder, mental retardation, depression and enuresis, respectively. The most common diagnosis in all age subgroups was ADHD. While the most common diagnoses in boys are ADHD, mental retardation, generalized anxiety disorder, enuresis and depression respectively, they were ADHD, generalized anxiety disorder, depression, mental retardation and enuresis in girls. Conclusion: To know the most common diagnoses, diagnosis differences within genders and possible diagnoses for certain age groups will be useful for improving child and adolescent psychiatry services.

Antidepressant and antipsychotic use in an Italian pediatric population.

BackgroundThe safety and effectiveness of psychotropic drug use in the paediatric population is widely debated, in particular because of the lack of data concerning long term effects.In Italy the prevalence of psychotropic drug prescriptions increased in the early 2000s and decreased afterwards. In such a context, a study with the aim to estimate the incidence and prevalence of psychotropic drug prescription in the paediatric population and to describe diagnostic and therapeutic approaches was performed.MethodsThe study population was composed of 76,000 youths less than 18 years and living in the area covered by the local health unit of Verona, Italy. The data source was the Verona local health unit's administrative prescription database. Prevalence and incidence of antidepressant and/or antipsychotic drug prescriptions in the 2004-2008 period were estimated. Children and adolescents receiving antidepressant and/or antipsychotic drug prescriptions between 1 January 2005 and 31 December 2006 were identified and questionnaires were sent to the prescribers with the aim to collect data concerning diagnostic and therapeutic approaches, and care strategies.ResultsThe prevalence of psychotropic drug prescriptions did not change in the 2004-2008 period, while incidence slightly increased (from 7.0 in 2005 to 8.3 per 10,000 in 2008). Between 1 January 2005 and 31 December 2006, 111 youths received at least one psychotropic drug prescription, 91 of whom received antidepressants. Only 28 patients attended child and adolescent psychiatry services. Information concerning diagnostic and therapeutic approaches, and care strategies was collected for 52 patients (47%). Anxiety-depressive syndrome and attention disorders were the diseases for which psychotropic drugs were most commonly prescribed. In all, 75% youths also received psychological support and 20% were prescribed drugs for 2 or more years.ConclusionsDespite the low drug prescription prevalence, the finding that most children were not cared for by child and adolescent psychiatric services is of concern and calls for a systematic, continuous monitoring of psychopharmacological treatments.

A randomized controlled trial of mother–infant psychoanalytic treatment: I. Outcomes on self‐report questionnaires and external ratings

Mother-infant relationship disturbances occur in three domains: maternal distress, infant functional problems, and relationship difficulties. They constitute common clinical problems. In Sweden, they are usually handled by nurses as part of public Child Health Centre care. Severe cases are referred to child psychiatry services. This randomized controlled trial compared two groups of mother-infant dyads in a Stockholm sample. One received only Child Health Centre care (the "CHCC" group) while the other received mother-infant psychoanalytic treatment plus CHCC (the "MIP" group). Eighty dyads of mothers and infants under 1½ years of age where the mothers had serious concerns about themselves in their role as mothers, their infants' well-being, or the mother-baby relationship were randomly selected for either the MIP or the CHCC group. The primary outcomes were mother-reported depression, mother-reported infant functional problems, and interviewer-based relationship assessments, all at 6 months after joining the project. Secondary outcomes were mother-reported stress and general psychic distress, externally rated video-recorded interactions, and the consumption of healthcare at the CHC, again all after 6 months. Intent-to-treat analyses of Treatment × Time effects significantly favored MIP treatment for maternal depression, mother-infant relationships, and maternal sensitivity. Effects were nearly significant on maternal stress, but nonsignificant on mother-reported infant functional problems, general psychic distress, maternal interactive structuring and nonintrusiveness, infant responsiveness and involvement, and healthcare consumption. MIP treatment improved mother-infant relationships and maternal sensitivity and depression, all of which are known to influence child development. If effects persist and are reproduced, MIP treatment holds promise for more widespread use.

Ethnic minority populations and child psychiatry services: An Irish study

Background Ethnically, Ireland has diversified greatly over the last twelve years changing from a country of emigration to one of immigration. Blanchardstown, a western suburb of Dublin, is one of the most ethnically diverse areas, with the youngest population in Ireland. Aims and methods This study aimed to examine any differences in referrals, clinical diagnoses and administrative outcomes of immigrants and Irish children referred to Blanchardstown Child and Adolescent Mental Health Service (CAMHS) over the period of one calendar year. Results Blanchardstown CAMHS received 202 referrals in 2007. There were 132 (65.5%) Irish and 65 (32.2%) immigrant children referred to the service. Nigerians accounted for more than a half of all immigrant children. Family doctors referred the majority of Irish children (58.4%; 77); non-Irish children were referred mainly by teachers (51%; 33) ( p < 0.05). In 2007 Blanchardstown CAMHS offered appointments to 116 families. Non-attendance rates at first appointments were similar in both groups (22.4% vs. 22.6%; p > 0.05); more immigrant children, however, dropped out following an initial appointment (16.1% vs. 2.4% p < 0.05). More non-Irish than Irish children were diagnosed with Axis-1 diagnosis (66.7% vs. 53.4%; p < 0.05). The two most common Axis-1 diagnoses among both non-Irish and Irish children were Attention Deficit Hyperactivity Disorder and Pervasive developmental disorders. Conclusions Immigrant children accounted for a substantial minority of children referred to Blanchardstown CAMHS. The psychiatric problems of immigrant children most often came to light through schools. More non-Irish children compare with Irish had an Axis-1 disorder.

Deliberate self-harm (DSH) out of hour's presentations.

To establish time of presentation to paediatric accident and emergency (A&E) services of children with deliberate self-harm (DSH). All children presenting to an acute paediatric hospital with DSH or suicidal ideation between 1993-2003 were identified and time of presentation collected from their case notes. Of the 172 children where the actual time of presentation was recorded, the majority of children - 137 (80%) presented to the hospital outside of the 'normal working hours' of 9am-5pm, Monday - Friday. These children represent an at-risk group, and were more likely to have consumed alcohol, to have made a suicide attempt, and to have a family history of psychiatric illness than children presenting with "normal working hours". DSH in young people is a significant public health problem in Ireland and is a major risk factor for completed suicide. Access to an out of hours on-call Child and Adolescent Psychiatry (CAP) services is essential if these children are to have a mental health assessment, as recommended by the Royal College of Psychiatry and National Institute of Clinical Excellence. These services need to be urgently developed.

Mental health policy and development in Egypt - integrating mental health into health sector reforms 2001-9

BackgroundFollowing a situation appraisal in 2001, a six year mental health reform programme (Egymen) 2002-7 was initiated by an Egyptian-Finnish bilateral aid project at the request of a former Egyptian minister of health, and the work was incorporated directly into the Ministry of Health and Population from 2007 onwards. This paper describes the aims, methodology and implementation of the mental health reforms and mental health policy in Egypt 2002-2009.MethodsA multi-faceted and comprehensive programme which combined situation appraisal to inform planning; establishment of a health sector system for coordination, supervision and training of each level (national, governorate, district and primary care); development workshops; production of toolkits, development of guidelines and standards; encouragement of intersectoral liaison at each level; integration of mental health into health management systems; and dedicated efforts to improve forensic services, rehabilitation services, and child psychiatry services.ResultsThe project has achieved detailed situation appraisal, epidemiological needs assessment, inclusion of mental health into the health sector reform plans, and into the National Package of Essential Health Interventions, mental health masterplan (policy guidelines) to accompany the general health policy, updated Egyptian mental health legislation, Code of Practice, adaptation of the WHO primary care guidelines, primary care training, construction of a quality system of roles and responsibilities, availability of medicines at primary care level, public education about mental health, and a research programme to inform future developments. Intersectoral liaison with education, social welfare, police and prisons at national level is underway, but has not yet been established for governorate and district levels, nor mental health training for police, prison staff and teachers.ConclusionsThe bilateral collaboration programme initiated a reform programme which has been sustained beyond the end of the funding. The project has demonstrated the importance of using a multi-faceted and comprehensive programme to promote sustainable system change, key elements of which include a focus on the use of rapid appropriate treatment at primary care level, strengthening the referral system, interministerial and intersectoral liaison, rehabilitation, and media work to mobilize community engagement.

PW01-96 - False diagnosis of mental retardation: WISC III test's place in a child psychiatry service

ObjectivesTo access the Intelligence Wechsler Scale for Children (WISC-III) as an auxiliary resource in the diagnosis of patients with suspected mental retardation.MethodsThirty patients were evaluated in a university psychiatric service for children and adolescents, consulted during 2008. Those patients underwent a psychiatric evaluation and, after, subsequently the WISC III scale was administered. Patients were classified, according to their intellectual coefficients, as with or without a mental retardation score, following ICD-10 criteria. The results were transferred to a SPSS (Statistical Package for Social Sciences) spreadsheet and then analyzed in its socio-demographic and clinic variables.ResultsOf the thirty patients, 18 (60%) were children and 12 (40%) adolescents; 22 (73,33%) were male and 8 (26,67%) female. Furthermore, the sample revealed that 20 (68,97%) patients had had an axis I diagnosis. For the participants, 7 (23,3%) had an IQ below the cutoff of 70, consistent with the mental retardation diagnosis, and agreeing with the psychiatric evaluation. The other 23 (76,7%) patients had an IQ within the normal range. From those considered intellectually deficient, 5 (71,43%) had a score for mild and 2 (28,57%) for moderate mental retardation.ConclusionsThis study showed that clinical diagnosis of mental retardation is difficult, especially for mild cases, when the characteristics are not very clear. The error probability is increased if an instrument such as WISC III is not administered. Therefore, WISC III is an important instrument in the diagnostic process for mental retardation, in many instances changing a first clinic impression.

P01-194 - Why patients do not attend - understanding the reasons for non-attendance at a child and adolescent psychiatry clinic

ObjectivesTo examine the reasons for non attendance at clinic appointments, and to identify any ways in which these rates might be reduced.MethodsWe examined the records of those patients who, having consented to a referral to a child and adolescent psychiatry service, then either failed to attend any appointments, or who ceased to attend after having attended one or more appointments, but without being discharged, over an 18-month period. The parents of these children were contacted by telephone and a semi-structured interview was conducted to ascertain the reason in each case for defaulting on the appointment.ResultsThe reasons given by the parents of the patients for missing appointments included their opinion that the referral was unnecessary (31.8%), resolution of the problem which led to the referral (22.7%), the child refusing to attend (22.7%) and problems with clinicians (9%). In the majority of cases where the parent did not consider the referral necessary, the referral had been made by the child's school (71%), with the parent reporting that they had felt pressurised into consenting to the referral.ConclusionThe high levels of non-attendance at clinics have serious implications, especially if it means that those in need of services are not accessing them. The factors which we have identified in this study are chiefly patient rather than service factors, which are likely to be related to socio-economic factors.

As perturbações emocionais - Ansiedade e depressão na criança e no adolescente

EMOTIONAL DISORDERS - ANXIETY AND DEPRESSION IN CHILDHOOD AND ADOLESCENCE Anxiety Disorder and Depressive Disorder are clinical entities of high prevalence in childhood and adolescence, and may be precursors of psychopathology in adulthood. For both reasons, early diagnosis and intervention become essential, as well as the identification of possible risk factors that enhance these disorders. Primary Health Care assumes, in this context, an important role in screening cases, as well as in intervention and possible referral to Child and Adolescent Psychiatry Services. In this article the authors briefly discuss aspects related to risk factors, prevalence, diagnosis, clinical intervention and prognosis for Anxiety Disorder and Depressive Disorder.

Mental Health of Immigrant Children: A New Challenge for Child and Adolescent Psychiatry Services in Ireland

Ethnically, Ireland has diversified greatly over the past few years. According to the 2006 census, 419733 foreign nationals live in Ireland. Immigration is one of the one of the most stressful events a child can undergo; it involves profound changes, including a disruption of well-established relationships and acculturation. Since the long-established and dominant pattern for years had been emigration, Ireland is poorly equipped to meet mental health needs of immigrant children.

Prevalence of treated autism spectrum disorders in Aruba

To study autism outside of a narrow range of settings previously studied, and in a particularly distinctive setting in the Caribbean. The aim of the Aruba Autism Project was to determine the prevalence of autism spectrum disorders (ASDs) in birth years 1990–1999 in Aruba. A record review study was conducted; cases were ascertained from children treated at the Child & Adolescent Psychiatry Clinic of Aruba, the first and only child psychiatry service on the island. In these 10 birth years we found a prevalence for autistic disorder (AD) of 1.9 per 1,000 (95% CI 1.2–2.8) and for autism spectrum disorders of 5.3 per 1,000 (95% CI 4.1–6.7). Comparison analysis with a cumulative incidence report from the UK, showed a similar cumulative incidence to age five in Aruba. Prevalence of ASDs in birth years 1990–1999 and cumulative incidence to age five in Aruba are similar to recent reports from the United Kingdom and the United States.

The Role of Nurse Practitioners in Meeting the Need for Child and Adolescent Psychiatric Services: A Statewide Survey

The high prevalence of child and adolescent mental health disorders coupled with shortages in age-appropriate mental health services pose a significant problem likely to be exacerbated over time. A survey was designed to identify the current status of and need for child and adolescent psychiatrists (CAPs) and mental health services, as well as strategies and recommendations to address identified needs in the state of New York. Key informants from each county and New York City were surveyed by telephone (N = 58). Most respondents identified a shortage of child and adolescent psychiatry services and reported that when CAPs are unavailable, nurse practitioners (NPs) are currently among the top four professional groups who prescribe and/or monitor psychotropic medication. Almost half of the respondents (48%) identified employing NPs with advanced certification in child and adolescent psychiatry as a promising strategy to improve access to care. Addressing the shortage of CAPs can provide an opportunity for the nursing profession to advance its role in the provision of mental health services to youth.

Child and adolescent psychiatry services in low- and middle-income countries

The theme in this issue concerns the interface between child psychiatric services in low- and middle-income countries and the availability of such services in higher-income countries. In neither context are such services ideal, and resources are relatively slim when compared with demand. The key issues are discussed in three terms: first, of the need for nations to have a general statement of child and adolescent mental health policy (Shatkin et al); second, of the need to establish international child and mental health research networks to foster research in low- and middle-income countries (Erlich & Plener); and third, of the circumstances that exist for providing such support to children in one such country, Pakistan (Khan et al).

Academic Training in a Child and Adolescent Psychiatry Fellowship: A Curriculum Based on Leadership Experience

The authors describe how one child and adolescent psychiatry fellowship program responded to emerging trends in clinical practice which increasingly demand that child and adolescent psychiatrists lead their colleagues through instruction and supervision. Data from surveys of recent graduates of child and adolescent training programs were reviewed and the trends were identified. The authors describe the Academic Chief Fellow rotation, which was designed for the fellows to enhance their academic skills by teaching, guiding, and supervising their junior colleagues. The authors describe the implementation of the new rotation and discuss the fellows' response. They also detail the responses of the medical students and residents who rotated on the child and adolescent psychiatry service under the Academic Chief Fellow. Greater experience in teaching and supervising others can be meaningfully integrated into existing child and adolescent psychiatry fellowship curricula. Other outcomes may include greater medical student and general psychiatry resident satisfaction with their child and adolescent psychiatry rotation and greater interest among medical students in child and adolescent psychiatry as a career.

Subconscious Guided Therapy with Hypnosis

Two adolescents were hospitalized with incapacitating symptoms: One with headache, back pain, and an inability to walk, while the other had headache, musculoskeletal pain, nausea, and emesis. Medical evaluation did not reveal an etiology for the symptoms of either patient. Consultation with child psychiatry services yielded recommendations that both patients might benefit from counseling. Both demonstrated an immediate improvement of their symptoms with instruction in self-hypnosis-induced relaxation techniques that included favorite place imagery and progressive relaxation. The patients were told that while in hypnosis their “subconscious” might be able to characterize psychological issues that underlay their symptoms through the medium of automatic word processing (AWP). The information identified through AWP helped guide their subsequent therapy. Thus, instruction in self-hypnosis, as well as helping adolescents develop awareness about the cause of their debilitating symptoms can be associated with rapid improvement of their symptoms.

The Mental Health of Asylum-seeking and Refugee Children and Adolescents Attending a Clinic in the Netherlands

We investigated the sociodemographic and clinical characteristics of asylum-seeking and refugee children and adolescents referred to a child and adolescent psychiatry service in the Netherlands. Children with families and unaccompanied minors were compared. Unaccompanied minors had significantly higher frequencies of symptoms and psychiatric disorders than the children with families, both considered a high-risk population for mental health problems.

A cost-minimization analysis of a telepaediatric mental health service for patients in rural and remote Queensland

The e-Child and Youth Mental Health Service (eCYMHS) is delivered by videoconferencing to nine rural and regional sites in Queensland. Between July 2004 and December 2006, a total of 317 videoconference clinics were offered, with 606 patient consultations. A cost-minimization analysis was undertaken to compare the actual costs of videoconference consultations with the potential costs of face-to-face consultations with the same specialists in Brisbane (i.e. patient travel) and the potential costs of face-to-face consultations in the regions (i.e. visiting psychiatrist). The actual cost of providing telepaediatrics during the 30–month period was $230,753 ($1 = US$0.86 or €0.63). The potential cost of patient travel was $650,389 and the potential cost of a visiting psychiatrist was $299,913. Videoconferencing was the cheapest method of delivering child psychiatry services when the workload exceeded 131 consultations (compared with patient travel) and 379 consultations for the visiting psychiatrist outreach service. Based on the actual workload observed in the study, the use of videoconferencing resulted in a net saving for the health service of about $420,000 compared with patient travel and $70,000 compared with a visiting outreach service.

Differences between prepubertal- versus adolescent- onset bipolar disorder in a Spanish clinical sample

To examine patients attended and diagnosed with bipolar disorder (BD) at a child and adolescent psychiatry service; to record age of diagnosis and age of onset, and to study clinical differences between prepubertal and adolescent onset groups. All patients currently attended for BD type I, type II or non specified BD were reviewed and divided into two age groups: prepubertal onset (beginning before age 13) and adolescent onset (beginning at or above age 13). The sample were 43 patients with BD. Fourteen (32.6%) with prepubertal onset and 29 (67.4%) with adolescent onset. Time between onset of symptoms and diagnosis was longer in the prepubertal onset group (1.2 years versus 0.8 years respectively, P = .05). Patients with prepubertal onset BD more frequently presented previous symptoms such as irritability and conduct problems and had a higher rate of comorbidity (more frequently attention-deficit/hyperactivity disorder-ADHD). The adolescent onset group more often presented psychotic symptoms. The clinical characteristics of patients with bipolar disorder differ according to whether onset is prepubertal or adolescent.

Videoconferencing in child and adolescent psychiatry in Finland – an inadequately exploited resource

To assess the current role of videoconferencing and the purposes for which it has been used in child and adolescent psychiatry in Finland, we sent a 16-item questionnaire to all providers of child and adolescent psychiatry services in specialised health care in Finland, i.e. the 42 child and adolescent units in 21 hospital districts. All service providers responded. The responses to both open-ended and structured questions were analysed manually and classified quantitatively and qualitatively. Use of videoconferencing was reported by 16 of the 21 hospital districts in Finland. Videoconferencing had been used for more than 5.5 years in only three hospital districts, for 3-5 years in 14 units and for 1-3 years in six units. Videoconferencing was used for clinical work in 12 and for distance education in another 12 hospital districts. Videoconferencing was used weekly for clinical work and for supervision by two districts; it was used for education by three districts. Although the workers' experiences of and attitudes towards videoconferencing were favourable, it has not been widely used in child and adolescent psychiatry. The implementation of videoconferencing seems to depend more on the activity of service providers than on the number of people involved.

Outcome of children with school refusal

To assess prospectively the psychiatric diagnostic status, psychosocial correlates, and short-term outcome of youngsters with school refusal. Thirty-three subjects (8-16 years) presenting with school refusal to a tertiary Child and Adolescent Psychiatry service were evaluated. Instruments administered at baseline and after 3 months (including an outcome measure at 3 months) were: The Missouri Assessment of Genetics Interview for Children (MAGIC) to ascertain psychiatric diagnoses, a modified version of Parent Interview Schedule (PIS), and the Children's Global Assessment Scale (CGAS). Twenty-nine subjects (87.9%) had a psychiatric diagnosis at baseline. Depressive disorder (63.6%) was commonest followed by specific phobias (30.3%). Psycho-social factors influenced school refusal in a majority (87.9%). Twenty of the thirty subjects (66.6%) who could be followed-up had returned to school. Psychiatric diagnosis persisted in 16 subjects. Younger age, being last-born, no or one diagnosis, and good baseline functioning predicted a favorable outcome. Psychiatric morbidity is high in a clinic population of youngsters with school refusal. It is associated with temperamental, family, and other environmental adversities. Short-term outcome in these children is largely favourable in terms of return to school and global functioning.