Practitioner Review Research Articles

Practitioner Review: The assessment of bipolar disorder in children and adolescents

An increasing number of youth are being diagnosed with, and treated for, bipolar disorder (BD). Controversy exists about whether youth with non-episodic irritability and symptoms of attention deficit hyperactivity disorder (ADHD) should be considered to have a developmental presentation of mania. A selective review of the literature related to this question, along with recommendations to guide clinical assessment. Data indicate differences between youth with episodic mania and those with non-episodic irritability in longitudinal diagnostic associations, family history, and pathophysiology. In youth with episodic mania, elation and irritability are both common during manic episodes. In diagnosing mania in youth, clinicians should focus on the presence of episodes that consist of a distinct change in mood accompanied by concurrent changes in cognition and behavior. BD should not be diagnosed in the absence of such episodes. In youth with ADHD, symptoms such as distractibility and agitation should be counted as manic symptoms only if they are markedly increased over the youth's baseline symptoms at the same time that there is a distinct change in mood and the occurrence of other associated symptoms of mania. Although different techniques for diagnosing comorbid illnesses have not been compared systematically, it appears most rational to diagnose co-occurring illnesses such as ADHD only if the symptoms of the co-occurring illness are present when the youth is euthymic.

Predictors of 10-year outcome of first-episode psychosis

Predictors of outcome for psychosis are poorly understood. Duration of untreated psychosis (DUP) appears to predict short-term outcome although its medium- to long-term role remains unclear. Neurodevelopmental indices such as pre-morbid function and/or neurological soft signs may predict longer-term outcome. We aimed to assess the impact of a range of clinical and demographic variables on long-term outcome of a geographically defined, epidemiological first-episode psychosis cohort. A 10-year follow-up was undertaken of a consecutively presenting sample of 109 cases of first-episode psychosis aged 16-50 years. Baseline assessments included positive, negative and depression symptoms, DUP, neurological soft signs and pre-morbid functioning. Multi-dimensional outcomes were assessed blind to baseline data. All participants were traced at a mean of 10.5 years post-index admission: 11 had died, 10 from non-natural causes. Of the surviving cases, 70% were comprehensively re-assessed by interview. Summary data on the remainder were collected from their family practitioner and chart review. Poor 10-year outcomes were predicted independently by poor pre-morbid functioning, baseline negative symptoms and longer DUP. The same measures, plus neurological soft signs, appeared to predict outcomes in a DSM-IV schizophrenia/schizo-affective subgroup. Poor pre-morbid functioning, baseline symptoms, DUP and neurological soft signs at onset independently predict poor long-term outcome in first-episode psychosis.

Applications for fees waivers on medical and psychiatric grounds at an Irish third-level college

Physical and mental illness present substantial challenges to college students and authorities. (1) To characterize medical and psychiatric reasons underlying requests for fees waivers at an Irish third-level college; (2) to identify information included in applications; and (3) to develop proposals for standardizing applications. We examined all applications for exemption from fees for medical or psychiatric reasons over two academic years at an Irish third-level college. Two hundred and twenty-two students applied for exemptions; 91% were successful. Psychiatric problems were more common than physical illness (64.1 vs. 27.9%). There was wide variation in details provided in applications with few providing details on likely ongoing duration of illness (5.0%). We recommend that (a) a structured medical application form be completed by medical practitioners supporting applications; (b) a medical practitioner review applications; and (c) there should be annual re-audit of this process.

Findings From South Korea Provide Insight Into XDR-TB

tee of the American Academy of Sleep Medicine (AASM) recommends CBT-I as first-line treatment for people with both primary and secondary chronic insomnia, including chronic hypnotic users (Morgenthaler T et al. Sleep. 2006; 29[11]:1415-1419). CBT-I usually reduces symptoms of chronic insomnia by 50%, according to Michael Perlis, PhD, associate professor of psychiatry at the University of Pennsylvania School of Medicine, Philadelphia, and director of its behavioral sleep medicine program. Patients who stick with CBT-I tactics—usually taught in 4 to 8 weekly individual or group sessions—often see symptoms fade by another 25% over the next few months. Treatment gains also last at least 2 years, said Perlis, who conducted a 3-day course to train physicians, psychologists, nurses, and others in CBT-I in Arlington, Va, in October. The University of Rochester Medical Center sponsored the event. One hurdle to broad use of CBT-I is the still small population of trained practitioners. To date, 136 doctorallevel US sleep specialists, including 42 physicians, have received AASM’s certification in behavioral sleep medicine, demonstrating knowledge and skill in CBT-I and other behavioral therapies. The AASM will start certifying master’s level practitioners in psychology, nursing, and other healthrelated fields in CBT-I in 2010 (http: //www.aasmnet.org/BSM.aspx). The nearly 1600 AASM-accredited sleep centers are required to have behavioral services available. Because CBT-I is time intensive for both clinician and patient, some sleep specialists are exploring shorter variants that, if effective, would be more practical in primary care settings. One such approach is a brief behavioral treatment for insomnia devised by researchers at the University of Pittsburgh School of Medicine. It consists of a 45-minute session in the primary care office, plus a booster session 2 weeks later. A master’s level nurse practitioner reviews sleep diaries, suggests ways to regularize daily schedules, advises patients to limit time in bed to time spent asleep, and provides a workbook with further instructions. Sleep quality and efficiency improved significantly more in 17 older adults receiving such help than in a matched control group receiving routine sleep habit advice (Germain A et al. J Clin Sleep Med. 2006;2[4]:403406). Self-directed computerized or Web-based CBT-I programs also are under evaluation, but Perlis remains skeptical about their utility. “CBT-I uses evidence-based methods, delivered in a way the patient finds compelling,” he said, “with a coach to follow up and foster compliance.” “Asking every patient, ‘How are you sleeping?’” he said, “elicits an excellent indicator of overall health. Some patients with insomnia can be managed medically, and some need referral to a sleep specialist. Proper treatment will reduce subsequent morbidity and health care utilization.”

Practitioner review: adolescent alcohol use disorders: assessment and treatment issues.

Alcohol use disorders in adolescents are associated with significant morbidity and mortality. Over the past decade, there has been a burgeoning of research on adolescent alcohol use disorders. A summary of the alcohol assessment tools is provided, and randomized studies reviewed and synthesized to provide an overview of state of the art knowledge of treatment of adolescent alcohol use disorders. Animal models of addiction are also briefly reviewed, and the value of translational research approaches, using findings from basic studies to guide the design of clinical investigations, is also highlighted. Comorbidity is the rule, not the exception in adolescent alcohol use disorders. Comprehensive assessment of psychiatric and other substance use disorders, trauma experiences, and suicidality is indicated in this population to optimize selection of appropriate clinical interventions. In terms of available investigated treatments for adolescents with alcohol use disorders, Multidimensional Family Therapy and group administered Cognitive Behavioral Therapies have received the most empirical support to date. There is a paucity of research on pharmacological interventions in this patient population, and no firm treatment recommendations can be made in this area. Given the high rate of relapse after treatment, evaluation of combined psychosocial and pharmacological interventions, and the development of novel intervention strategies are indicated.

Acknowledgment of Ad Hoc and Practitioner Reviewers

Acknowledgment of Ad Hoc and Practitioner Reviewers

Theory and legitimacy in professional education: a practitioner review of reflective processes within programmes for new academic staff

The authors review research literature on coherent theoretically based approaches to the use of reflective processes within programmes of initial professional education for new academic staff. Employing a novel methodology that incorporates practitioner perspectives, they establish a framework that highlights the role of personal and social factors, and also pedagogic and theoretical considerations, in shaping reflective processes. The included studies identified participants who had engaged in certain categories of reflection. Certain fundamental outcomes, however, such as changes in professional commitment, were never seen across an entire cohort. The article thus discusses the intended learning outcomes that programmes might legitimately seek to meet. Dans cet article, nous examinons la littérature de recherche portant sur les approches théoriques cohérentes sur l’usage des processus réflexifs dans le cadre de programmes d’éducation professionnelle initiale pour le personnel académique novice. A l’aide d’une nouvelle méthodologie incorporant les perspectives du praticien, nous établissons un cadre qui met en lumière le rôle des facteurs sociaux et personnels, de même que les considérations théoriques et pédagogiques, mettant en forme les processus réflexifs. Les études visées par l’article ont permis d’identifier des participants s’étant engagés dans certaines catégories de réflexion. Des conséquences fondamentales, telles que le changement au niveau de l’engagement professionnel, n’ont cependant pas été observés pour l’ensemble de la cohorte. Nous discutons donc des objectifs d’apprentissage que les programmes pourraient, de façon légitime, chercher à atteindre.

Practitioner review: How can epidemiology help us plan and deliver effective child and adolescent mental health services?

This review focuses on ways in which epidemiological research can inform mental health service development and clinical practice. Data from epidemiological studies can provide cross-sectional and secular estimates of the prevalence of psychopathology to support rational service development. Epidemiological surveys have difficulties in finding large enough samples of children with rare disorders, although these disorders are often severely debilitating and require extensive service input. Systematic surveillance provides a rigorous method for studying rare disorders and events. Only a minority of children with impairing psychopathology reach mental health services, although a larger proportion have mental health related contacts with other services. The gap in provision is such that an expansion of mental health services is unlikely to reach all children who could benefit, suggesting that mental health professionals need to develop innovative strategies to increase the number of children seen and the effectiveness of interventions that they receive. Training and supervision of non-mental-health professionals working with children in the identification and management of mental health problems is also extremely important. Most studies suggest that the children with the severest problems are getting to specialist mental health services, and service contact is more likely if important adults can perceive the child's difficulty or find it to be burdensome. The latter suggests that education of key adults would improve detection if services had the capacity to cope. Studies consistently suggest that the region in which the child lives affects the likelihood of service contact, but studies of other characteristics predicting service contact are so contradictory that studies should only be (cautiously) applied to similar populations to assess which types of children may currently be falling through gaps in service provision. Academics are beginning to explore the use of structured measures developed for epidemiological studies in clinical assessment and outcome monitoring.

Acknowledgment of Ad Hoc and Practitioner Reviewers

Acknowledgment of Ad Hoc and Practitioner Reviewers

Assessment of adolescent self-harm

This practitioner review suggests an approach to adolescents who harm themselves, principally by self-poisoning or self-cutting. Such adolescents frequently pass through the care of paediatricians, who may feel that they are not trained adequately to help them. The presentation of self-harm to health professionals provides an important opportunity for secondary prevention of repeated self-harm and suicide. To achieve this, all those in contact with such adolescents need to be aware of the pain and distress that lead them to a position where self-harm seems the best coping strategy. The practicalities of engagement, history-taking, observation and what to do next are discussed. Although informed by the latest guidelines, research and psychiatric understanding, the review is intended to be a practical guide based on personal experience.

Practitioner Review: Clinical applications of pediatric hypnosis

Over the past quarter century, hypnosis has been employed in a broad range of pediatric clinical settings; however, its efficacy and feasibility as a treatment approach for children and adolescents remain in question. Published studies on the role of clinical hypnosis in the management of specific pediatric medical and psychological conditions were identified and reviewed. Pediatric clinical hypnosis has been employed in diverse medical settings to treat primary conditions (e.g., enuresis), as well as to address factors related to management of the condition (e.g., skills training for asthma) or its treatment (e.g., burn dressing changes). Despite great breadth to the possible applications of pediatric hypnosis and many reported successes, much of the present research comprises case histories and small, uncontrolled group studies. To date, research in pediatrics views clinical hypnosis as a promising tool with the potential to help manage a variety of conditions. However, additional research, particularly utilizing randomized, controlled methodologies and adequate sample sizes, is required.

Editorial: The well‐being of children: empirical findings and implications for prevention and intervention

Editorial: The well‐being of children: empirical findings and implications for prevention and intervention

Editorial

Editorial

What is Necessary to Ensure Natural Justice for Community Participants in Sustainability Decision-Making?: Natural Justice in Sustainability Decision-Making

International practices for environmental and sustainability decision-making with respect to expectations to uphold natural justice or procedural fairness through full engagement of public stakeholders concerning all information used to guide decisions are reviewed. Best practice principles that emerge from a literature review and survey of international practitioners from the impact assessment field are evaluated. The concept of natural justice relates to a duty to involve those affected by new development proposals to be involved in approval decision-making through meaningful consultation and participation. This includes fully explaining the reasons for a decision that has been made and reasonable provisions for appealing against decisions taken. Typically, natural justice is not something that is prescribed in law but emerges from practice and customs. The more advanced systems of impact assessment generally provide for a high level of transparency, accountability and public participation in decision-making. In systems where the advice to the decision-maker is available for public comment, there is a greater expectation for full disclosure of information relevant to decision-making. The nature of the legal direction provided for the basis of decision-making has direct bearing on the level of public involvement in decision-making. Decision-making by elected ministers is generally less transparent than that at the level of government agencies, and expectations of practitioners concerning natural justice varies accordingly. Balance has to be struck between efficiency of process and provision of endless opportunity for public participation in decision-making - provision of appeal rights along with full disclosure of the reasons behind a decision are important here. Ultimately some judgement is required by decision-makers to decide when and how much information should be disclosed to stakeholders on a case by case basis, realising however, that a fair process is ultimately likely to lead to the most sustainable outcome and in the most efficient way.

Editorial

Editorial

Practitioner Review: Assessment and treatment of refugee children and adolescents who have experienced war‐related trauma

Increasingly clinicians are being asked to assess and treat young refugees, who have experienced traumatic events due to war and organised violence. However, evidence-based guidance remains scarce. Published studies on the mental health difficulties of refugee children and adolescents, associated risk and protective factors, as well as effective interventions, particularly those designed to reduce war-related post-traumatic stress disorder (PTSD) symptoms, were identified and reviewed. The findings are summarised. Young refugees are frequently subjected to multiple traumatic events and severe losses, as well as ongoing stressors within the host country. Although young refugees are often resilient, many experience mental health difficulties, including PTSD, depression, anxiety and grief. An awareness of relevant risk and protective factors is important. A phased model of intervention is often useful and the need for a holistic approach crucial. Promising treatments for alleviating symptoms of war-related PTSD include cognitive behavioural treatment (CBT), testimonial psychotherapy, narrative exposure therapy (NET) and eye movement desensitisation and reprocessing (EMDR). Knowledge of the particular needs of unaccompanied asylum-seeking children (UASC), working with interpreters, cross-cultural differences, medico-legal report writing and the importance of clinician self-care is also necessary. More research is required in order to expand our limited knowledge base.

Practitioner Review: Psychosocial interventions for children with selective mutism: a critical evaluation of the literature from 1990–2005

There have been several reports of successful psychosocial interventions for children with selective mutism (SM), a disorder in which a child consistently fails to speak in one or more social settings (e.g., school) despite speaking normally in other settings (e.g., home). The present literature review was undertaken in order to provide an up-to-date summary and critique of the SM treatment literature published in the past fifteen years. PubMed, PsycINFO, and Web of Science databases were searched to identify SM treatment studies published in peer-reviewed journals between 1990 and 2005. A total of 23 studies were included in the present review. Of these, ten used a behavioral/cognitive behavioral approach, one used a behavioral language training approach, one used a family systems approach, five used a psychodynamic approach, and six used multimodal approaches to SM treatment. Although much of this literature is limited by methodological weaknesses, the existing research provides support for the use of behavioral and cognitive-behavioral interventions. Multimodal treatments also appear promising, but the essential components of these interventions have yet to be established. An outline of a cognitive-behavioral treatment package for a typical SM child is provided and the review concludes with suggestions for future research.

Acknowledgment of Ad Hoc and Practitioner Reviewers

Acknowledgment of Ad Hoc and Practitioner Reviewers

Learning at school and in real‐life: providing an optimal setting for children

Learning at school and in real‐life: providing an optimal setting for children

Functional Limitations From Pain Caused by Repetitive Loading on the Skin: A Review and Discussion for Practitioners, With New Data for Limiting Friction Loads

Reddened painful skin, areas where the outermost layer of skin has been rubbed off (abrasions), and blisters are very common problems observed daily by orthotists, prosthetists, pedorthists, athletic trainers, and a host of other caregivers. These examples of acute skin trauma and the pain that precedes and/or accompanies them are often what determine the limits of an individual’s functional performance. When these problems occur within footwear, orthoses, or prosthetic sockets, the cause is repetitive loading—a combination of peak load magnitude and number of loading cycles sufficient to produce significant skin trauma. Walking, running, and many other activities involve movements of skeletal elements relative to surfaces such as shoe insoles, orthoses, and prosthetic sockets. Those relative movements are an inevitable consequence of transferring load through soft tissue and across the skin interface. The loads contain both normal (perpendicular to the skin surface) components and friction (parallel to the skin surface) components. Historically, most instances of skin trauma have been attributed directly to excess pressure and have been dealt with using pressure-management techniques exclusively. Pressure-reduction techniques do often lead to some improvement. However, the assumption that those problems are directly governed by excess pressure is substantially in error, leading to partial solutions and missed opportunities to achieve much higher levels of safe, pain-free function. Research has established the friction component of repetitive loadings to be the major factor governing how many load cycles a given area of skin can tolerate before the onset of pain and acute trauma. To increase comfortable, pain-free function, the magnitude of friction load peaks applied each loading cycle must be reduced. This can be accomplished by reducing peak normal (pressure) load magnitudes and/or reducing the coefficient of friction (COF) operating between the skin and support surface in the problem area. Friction forces over the vast majority of the loaded skin surface area are useful for stability, suspension, and the transmission of functional forces. Friction creates a problem only in very limited areas. This is the rationale for reducing the operative COF in problem areas only.