Contemporary characteristics of the developmental age psychopathology

At present time, it may seem that the available therapeutic possibilities and methods have resulted in lower prevalence, and even disappearance, of certain psychopathological entities. The advancement of therapeutic methods has made possible to tackle new issues that are emerging in developmental psychopathology. These issues are directly related to the specifics of the current social sphere, reflecting the turbulent social changes as consequences of globalization and economic instability in the world. Humanitarian crises are ever more often accompanied by increased prevalence of mental disorders and psychological distress of the population in general. Based on child psychiatrists' reports from all corners of the globe, it is evident that the features of developmental psychopathology are constantly changing. The research studies refer to social events and phenomena that in previous decades were not to be found at the fore of clinical entities distribution. Thus, there are research reports on personality disorders in developmental age. Some thirty years ago, opinions were still divided on whether or not there existed personality disorders in developmental age. Nowadays, however, it is an accepted fact among experts that these disorders in youth warrant attention. This prevailing view has instigated research in this domain and now projects are carried out in many countries, so it is safe to say that the research has become global. Furthermore, the researchers' pay much attention to the problem of suicide both in youth and in children. Some special areas of research are being identified, such as the suicide risk assessment in adolescents undergoing short term antidepressant therapy. Latest data show that researchers are more often engaged in parent education, teaching them behaviours they need to raise a child with hyperactivity syndrome. Also, research results on the quality of emotional relationship with adoptive parents have been published with increasing frequency, especially by American authors. The results show that social services are detecting more and more cases of abuse of adopted children. Psychosomatic illnesses and liaison therapy at paediatric wards also feature prominently in current psychopathology. They are followed by issues of mental health of populations in humanitarian crises, including war, hard physical labour and abuse of child labour. The presentation includes a brief overview of psychopathology from the local perspective, with latest examples from clinical practice. The presentation concludes with the constatation that peculiarities of child and adolescent psychopathology follow the dynamic corresponding to the global social changes and increasing economic problems.

The copycat phenomenon after two Finnish school shootings: an adolescent psychiatric perspective

BACKGROUND

Two school shootings with altogether 18 victims took place in Finland in November 2007 and September 2008. Homicides and suicides are both associated with the copycat phenomenon. The aim of the present study was to characterize adolescent copycats who had threatened to carry out a school massacre.

METHODS

The nation-wide study evaluated 77 13- to 18-year-old adolescents who were sent for adolescent psychiatric evaluations between 8.11.2007 and 30.6.2009, one of the reasons for evaluation being a threat of massacre at school. The medical files of the copycats were retrospectively analysed using a special data collection form. Data on demographics, family- and school-related issues, previous psychiatric treatment and previous delinquency, current symptoms, family adversities and psychiatric diagnoses were collected. The severity of the threat expressed and the risk posed by the adolescent in question were evaluated. The Psychopathy Checklist Youth Version was used to assess psychopathic traits.

RESULTS

All of the copycats were native Finns with a mean age of 15.0 years. Almost two thirds of them had a history of previous mental health treatment before the index threat. Almost two thirds of the copycats suffered from anxiety and depressive symptoms, and almost half of the sample expressed either suicidal ideation or suicidal plans. Behavioural problems including impulse control problems, aggressive outbursts, the destruction of property as well as non-physical and physical violence against other persons were common. The diagnosis groups highlighted were behavioural and emotional disorders, mood disorders as well as schizophrenia-related disorders. The prevalence of pervasive developmental disorders was high. Only one of the copycats was assessed as expressing high traits of psychopathy.

CONCLUSION

The copycats with school massacre threats were characterized with a high prevalence of mental and behavioural disorders. Like actual school shooters, they showed psychotic symptoms and traumatic experiences, but unlike the shooters, the copycats were not psychopathic.

[Diagnostic difficulties in adolescent patients--subjective psychiatrist-side factors]

Adolescence is a period of intensive development and crucial transitions in human life. Developmental crises, oppositional behaviours and non-adaptive patterns are strengthened. Simultaneously some symptoms of mental disorders appear mostly in poor organised, non-specific prodromal syndromes. In these unstable and developmentally modified conditions psychiatric diagnosis and treatment seems to be very difficult. In the paper, we described the influence of countertransference of the psychiatrist on the diagnostic processes, especially the influence of a psychiatrist's adolescence on his/her unconscious attitude to adolescence at all.

Attuned Practice: a service user study of specialist child and adolescent mental health, UK

Aims – Best practice emphasises user involvement. This exploratory study addresses the views of teenage clients and their parents on service delivery in a specialist Child and Adolescent Mental Health Service (CAMHS) serving a population of 250,000. It aims to explore some of the complexities inherent in children's services when parents are integral to modes of treatment. Methods — Twenty-seven teenage clients from specialist CAMHS were recruited with their parents (n=30). All were white British, 11 boys and 16 girls, from a range of socioeconomic backgrounds. Focus groups were employed using a series of structured interactive technique to elicit information, preceded by home visits. Analysis of interview data followed standard approaches to qualitative data analysis. Descriptive statistics were generated from both home interview data and focus groups. Results – Three themes emerged: the core values implicated in establishing a therapeutic alliance; the style of therapy and mode of practice (i.e. its inclusiveness of different family members). Practice implications – Core therapeutic skills are of fundamental importance. Our paper supplements a model of organisational user involvement with a model of therapeutic user involvement for use in negotiating mode of practice. Conclusions – This exploratory study was a collaboration between service users, researchers and health professionals exploring three important themes of therapy and the complexities inherent in children's services. The process of eliciting views was therapeutic in itself leading to the formation of a parent-led self-help group. The design can be replicated in other specialist CAMHS to achieve attuned practice.

Declaration of Interest: none.

Psychotropic medication use in children and adolescents in an inpatient setting

Medication can be an effective part of treatment for several psychiatric disorders of childhood and adolescence but its use should be based on a comprehensive psychiatric evaluation and treatment plan. The aim of this study was to evaluate psychotropic medication use for children and adolescents treated as inpatients and to compare it with principles of rational pharmacotherapy, thus identifying possible downsides of current practices and pointing a way towards safer and more efficient practices. This is a descriptive study of prescribing trends at the Clinical Department for Children and Adolescents of the Institute of Mental Health in Belgrade, during the period from September 2009 to September 2010. Analyzed demographic data (age, gender) and the number of hospitalizations were obtained from medical histories, while diagnoses were obtained from discharge notes. Prescribed therapy was copied from medication charts. Drug dosages were analyzed as average daily doses prescribed during the hospitalization. Psychiatric diagnoses were classified according to The International Classification of Diseases and Related Health Problems, 10th Revision (ICD-10). During the examined time period, 264 patients were hospitalized (61.4% males), with an average age of 11.4±5.1 years. We have found that 66.3% of admitted patients were treated with pharmacotherapy in addition to other treatment modalities. There was a highly significant correlation between the age of patients and the prescribed dosage (Spearman's rho=0.360, p<0.001) as well as the number of prescribed drugs (Spearman's rho=0.405, p<0.001). The most commonly diagnosed psychiatric disorders were: autism spectrum disorders (20.8%), conduct disorders(19.7%), mixed developmental disorder (14.8%), adjustment disorder (7.2%), mental retardation (7.2%),acute psychosis (4.5%), and ADHD (2.3%). The most commonly prescribed medications were antipsychotics(45.9%), followed by antidepressants (17.2%), mood stabilizers (16.1%), benzodiazepines (14.4%), and other psychotropic drugs (6.4%). The most commonly prescribed antipsychotic was risperidone, used for more than 50% of the patients treated with antipsychotics. Taken together risperidone and chlorpromazine were more than 75% of all prescribed antipsychotics. 98.4% of prescribed antidepressants belonged to the SSRIs,with sertraline and fluoxetine accounting for almost 90% of them. All prescribed dosages were in accordance with the official guidelines. This is the first survey in Serbia to document the practice of prescribing psychotropic medication in the field of child and adolescent psychiatry. Current drug-prescribing practices at the Clinical Department for Children and Adolescents of the Institute of Mental Health in Belgrade are in accordance with current practices in the United States and Europe. Not every child with symptoms of mental health problems needs pharmacological treatment; when they do, the general rule of thumb should be "start low, go slow, and taper slowly". Follow-up studies are necessary to assess the change of trends, as well as studies in different patient populations and health centers, in order to globally evaluate psychotropic medication use in children and adolescents in Serbia.

Implementation of problem-based learning in child and adolescent psychiatry: shared experiences of a special-interest study group

BACKGROUND/OBJECTIVE

Problem-based learning (PBL) represents a major development and change in educational practice that continues to have a large impact across subjects and disciplines worldwide. It would seem that child and adolescent psychiatry, because of its inherently integrative, bio-psycho-social nature and emphasis on teamwork and collaboration, would be a specialty learned optimally through PBL. Thus, there was a need to establish an international group where experiences in implementing PBL in child and adolescent psychiatry could be shared. This article reports on the first meeting and plans of the Problem-Based Learning in Child and Adolescent Psychiatry (CAP) Special Interest Study Group (SISG), held at the annual meeting of the American Academy of Child and Adolescent Psychiatry.

METHODS

Through international collaboration and information-sharing, the SISG aims to promote knowledge among Child and Adolescent Psychiatrists on PBL, to explore evaluation methods of PBL in CAP, and to discuss development of PBL-based curricula.

RESULTS

Problem-based learning (PBL) represents a major change in education that has had a large impact across disciplines worldwide.

CONCLUSION

The core steps in PBL are the following: presentation of the initial problem; discussion of the problem, and development of learning objectives; independent learning focused on the objectives; and discussion, exploration of new ideas, and discovery of solutions in the reconvened group. Different from the traditional teacher's role, the PBL tutor is an active facilitator who guides learners to identify issues and ways to learn, rather than a "content expert" who provides facts.

Psychiatry trainees' training and experience in fetal alcohol spectrum disorders

BACKGROUND/OBJECTIVE

Alcohol is a teratogen. Fetal alcohol spectrum disorders (FASDs) affect about 1% of live births, causing severe impairment. Individuals affected by FASDs are overrepresented in psychiatric settings. This study reports on the education and experience of psychiatry trainees in approaching FASDs.

METHOD

Data were collected from psychiatry trainees throughout the country by use of a web-based questionnaire.

RESULTS

A representative sample (N=308) of psychiatry trainees responded; 19% rate their education on FASDs as "good" or "excellent," and 89% report that they would like more education on FASDs: 6%, 15%, and 30%, endorsed the statement "It is safe to drink some alcohol" during the 1st, 2nd, and 3rd trimesters, respectively. Only 31% correctly report that individuals with an FASD are at equal risk for adverse outcomes as individuals with full-blown fetal alcohol syndrome.

CONCLUSIONS

results reveal that training on FASDs is inadequate. Psychiatry trainees poorly understand the importance of abstinence throughout pregnancy. Trainees who report receiving supervision specifically addressing FASDs also report making the diagnosis much more frequently, suggesting that supervision in clinical settings is effective teaching. Results reveal that FASDs are underrecognized, resulting in missed opportunities for prevention and intervention.

A pilot study of social competence group training for adolescents with borderline intellectual functioning and emotional and behavioural problems (SCT-ABI)

BACKGROUND

Emotional and behavioural problems as well as a lack of social competence are common in adolescents with borderline intellectual functioning and impair their social and vocational integration. Group interventions specifically developed for this target group are scarce and controlled evaluation studies are absent.

METHODS

A cognitive-behavioural group training (Social Competence Training for Adolescents with Borderline Intelligence) was developed and its effectiveness was examined in students attending special vocational schools. A total of 77 adolescents with borderline intelligence were randomised either to the intervention (n=40) or to the control group (n=37). Outcome measures at post-treatment and at a 6-month follow-up comprised self-reports, caregiver reports and behavioural observations.

RESULTS

The adolescents in the intervention group showed temporally stable improvement in their social competence, especially in social problem solving (F=17.6, P<0.001) and attainment of individual behavioural goals in everyday life (self-reports: F=15.9, P<0.001; caregiver reports: F=87.9, P<0.001). Effects of the intervention on other outcomes such as problem-solving competence and skills performed in standardised role plays were weak or absent.

CONCLUSIONS

Social Competence Training for Adolescents with Borderline Intelligence is a promising treatment for adolescents with borderline intellectual functioning and associated emotional/behavioural symptoms. Further studies examining long-term effects on the participants' social and vocational integration are needed.

Cognitive behavioural therapy and young people: an introduction

Cognitive behavioural therapy (CBT) is a form of psychotherapy or "talking cure" that has been shown to be effective for a wide range of psychological problems and shows promise in many others. Up to now it has been used more with adults but there is a growing body of evidence of its usefulness in children and young people for conditions that include depression, generalised anxiety disorder, obsessive compulsive disorder, school phobia, eating disorders, self-harm and conduct problems.

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

BACKGROUND

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.

METHODS

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.

RESULTS

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.

CONCLUSIONS

Given the high rate of relapse after treatment, evaluation of combined psychosocial and pharmacological interventions, and the development of novel intervention strategies are indicated.

Reinventing family therapy: teaching family intervention as a new treatment modality

OBJECTIVE

This article discusses the pedagogy of teaching family therapy in the new millennium. It draws on the strengths of "family systems therapy" but goes beyond it-suggesting a new paradigm, new terminology, and a new teaching perspective. It discusses the historical background of family therapy training, a scientific foundation for what residents should be taught, and an integrative clinical model for how it could be taught.

METHODS

The article is the synthesis of the perspectives and experience of a child and adolescent psychiatrist educator who began his career at the end of the systemic era in psychiatry and continues it through the developments of the neurobiologic era. It draws on selected literature from the fields of family therapy, child and adolescent psychiatry, developmental psychopathology, and general psychiatry.

RESULTS

This article submits that the term "family therapy" should be replaced by the term "family intervention"; the evidence base indicates that family interventions are effective; family risk and protective factors influence the onset and course of disorders; families help shape and maintain cognitive schema; intervention must start with thorough case formulation; and family interventions should be coordinated with other interventions, include parent management training, and build on family strengths.

CONCLUSION

Family intervention is an important clinical process in child and adolescent psychiatry, and contemporary education must address the multiple ways clinicians can assist families. Future models will be successful to the degree they build on the past contributions of systems thinking and include the perspectives of developmental psychopathology. Contemporary education should teach that family interventions are not optional but ideally can be integrated with other interventions in a sequential manner, emphasizing the interrelationship between self and system.

Implementation of MET/CBT 5 for adolescents

Implementation of effective substance abuse treatment programs in community settings is a high priority. The selection of a proven cost-effective model is a first step; however, difficulty arises when the model is imported into a community setting. The Center on Substance Abuse Treatment selected a brief substance abuse treatment program for adolescents, the MET/CBT-5 program, determined to be the most cost-effective protocol in the Cannabis Youth Treatment trial, for implementation in two cohorts of Effective Adolescent Treatment grantees. A qualitative investigation of the protocol implementation with nine sites in the second cohort chronicled adaptations made by grantees and prospects for sustainability. The study found that agencies introduced adaptations without seeming to be aware of potential effects on validity. In most sites, sessions were lengthened or added to accommodate individual client needs, address barriers to client participation, and provide consistency with current norms of treatment. Implications for fidelity of future implementation projects are addressed.

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.

Pediatric obsessive-compulsive disorder: a guide to assessment and treatment

Obsessive-compulsive disorder (OCD) is an anxiety disorder characterized by recurrent or persistent thoughts, impulses, or images that are experienced as intrusive or distressing (obsessions), and repetitive behaviors or mental acts (compulsions) often performed in response to an obsession. Recent epidemiological studies have found lifetime prevalence of pediatric OCD to be approximately 1-4% in the USA. OCD begins before the age of 18 years for as many as 80% of cases and follows a chronic, unremitting course. Due to the distressing, time-consuming, and debilitating nature of OCD, impairments in academic, social, and family functioning are often substantial. Despite the relatively high prevalence rate of OCD, dissemination about effective assessment and treatment has lagged. Increasing the awareness of OCD symptoms and its treatment among nurses and other health professionals will enhance identification of children presenting with unrecognized or untreated symptoms of OCD and will stimulate appropriate referrals for treatment to improve children's psychological functioning and overall quality of life. This paper reviews the nature, etiology, assessment, and treatment of OCD, highlighting clinical implications for nurses involved in mental health care.

Transparent criteria for specialist level adolescent psychiatric care

BACKGROUND

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.

OBJECTIVE

To create and test the psychometric properties of a point-count measure for prioritising entry to public specialist level adolescent psychiatric services.

METHOD

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.

RESULTS

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.

CONCLUSION

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.

Evidence-based and values-based policy, management and practice in child and adolescent mental health services

Values-based practice is a new approach to working with complex and conflicting values. It is based, primarily, on learnable skills and is being applied across a range of policy, training and service development initiatives in mental health and social care. This article outlines some of the key features of values-based practice including its complementary relationships to both regulatory ethics and evidence-based practice. We describe the systemic links between values-based approaches at the three key levels of policy, service development, prioritization and commissioning, and clinical practice and managing delivery of services, particularly as they are being developed in child and adolescent mental health services. Our article concludes by indicating some of the areas for further development of values-based practice.

Recent non-medication trials of interpersonal psychotherapy for depression

Interpersonal psychotherapy (IPT) is a time-limited treatment described in a manual and tested in numerous clinical trials, with and without medication. Four recent clinical trials are reviewed in situations where medication as a first-line treatment for depression was not feasible (pregnancy, post partum, adolescence and in a developing country). The results show the efficacy of 12-16 wk of IPT compared to treatment as usual or no treatment in reducing depressive symptoms. The therapists providing the treatment included psychiatrists, psychologists, social workers as well as non-mental-health workers. We do not know if these patients might have done even better with medication, but each study showed a significant remission of symptoms of patients in IPT compared to controls. The use of efficacious, time-limited psychotherapy, which can be administered by non-medical personnel can be economical. An obstacle to providing evidence-based psychotherapies is the paucity of practitioners trained in them. Until the gap between training in psychotherapy and the research evidence in psychotherapy is bridged in training programmes, it will be difficult to provide patients with these treatments.

Umgang mit jugendlichen Patienten zur Erfassung von Noxen in der Adoleszenz

Der altersangemessene Umgang mit jugendlichen Patienten ist eine wichtige Voraussetzung für die Erfassung der Einwirkung von Noxen in der Adoleszenz. Das Angebot zu einem Gespräch mit dem Arzt allein, die Zusicherung des eingeschränkten Patientengeheimnisses auf Wunsch hin auch gegenüber den Eltern sowie eine nicht urteilende Haltung des Arztes sind wichtige vertrauensfördernde Elemente für die erfolgreiche Gesprächsführung über den Konsum von psychoaktiven Substanzen und andere potentiell auf die jugendliche Person einwirkende Noxen. Um das Patientengeheimnis auch gegenüber den Eltern wahren zu können, sind die Urteilsfähigkeit der jugendlichen Person sowie mögliche Selbst- und Fremdgefährdung abzuklären. Das wiederholte Gespräch mit jugendlichen Patienten über potentielle Noxen in der Adoleszenz sollte ein fester Bestandteil der Arztkonsultation bilden, um einen Beitrag zur umfassenden Gesundheitsförderung zu leisten.

A pragmatic approach to teaching psychiatry residents the assessment and treatment of religious patients

OBJECTIVE

The authors describe a pragmatic and atheoretical frameword for teaching psychiatry residents how to assess and treat religious patients.

RESULTS

The psychiatrist's goals in assessing the religious history are clarified. These goals differ between the assessment and treatment phases. During assessment, attention is paid to psychiatric phenomenology and careful history-taking, utilizing knowledgeable outside informants. A framework is presented for engaging religious patients, fostering therapeutic alliance, avoiding pitfalls, and facilitating treatment within the patient's religious context.

CONCLUSIONS

Emphasizing knowledge of phenomenology and information gathering skills may be more effective than emphasizing broad knowledge of many religions, except for clinicians practicing within a particular religious community.