Diagnosis and evaluation of hallucinations and other psychotic symptoms in children and adolescents

Recognizing positive psychotic symptoms and their diagnostic context in youth is challenging. A large minority say they "hear things others do not hear," though they seldom present with complaints of hallucinations or delusions. Few have schizophrenia spectrum disorder, but many have other psychiatric disorders. Frequently, they have psychotic symptoms for an extended period before diagnosis. Clinicians should understand psychotic symptoms and their differential diagnoses. This article reviews the epidemiology, associated diagnoses, and prognosis of hallucinations and delusions in youth. Strategies for optimizing the clinical diagnostic interview, appropriate laboratory tests, indications for psychological testing, and rating scales are reviewed.

[Is my child normal, doctor? The specifics of child psychiatric examination]

The psychiatric assessment of a child requires to integrate the symptoms presented, for example, the child's suffering, in an array of complex family interactions The consultation process is difficult for parents and child, but also for the physician. Many pitfalls exist for everyone, namely the stigma attached to a disease, the search for normality at any price, the seduction of a reductive explanatory theory, and especially the oversight of the child's evolutionary potential. Finally, the characteristics of examination vary at each age; the differences may be major and depend on the development of the child in the process of empowerment.

Harnessing innovative technologies to advance children's mental health: behavioral parent training as an example

Disruptive behaviors of childhood are among the most common reasons for referral of children to mental health professionals. Behavioral parent training (BPT) is the most efficacious intervention for these problem behaviors, yet BPT is substantially underutilized beyond university research and clinic settings. With the aim of addressing this research-to-practice gap, this article highlights the considerable, but largely unrealized, potential for technology to overcome the two most pressing challenges hindering the diffusion of BPT: (1). The dearth of BPT training and supervision opportunities for therapists who work with families of children with disruptive behaviors; and (2). The failure to engage and retain families in BPT services when services are available. To this end, this review presents a theoretical framework to guide technological innovations in BPT and highlights examples of how technology is currently being harnessed to overcome these challenges. This review also discusses recommendations for using technology as a delivery vehicle to further advance the field of BPT and the potential implications of technological innovations in BPT for other areas of children's mental health are discussed.

[Gender identity disorder and related sexual behavior problems in children and adolescents: from the perspective of development and child psychiatry]

The present paper reviews the theoretical and empirical literature on children and adolescents with gender identity disorder. The organizational framework underlying this review is one that presents gender behavior in children and adolescents as a continuum rather than as a dichotomy of normal versus abnormal categories. Theories of normative gender development, prevalence, assessment, developmental trajectories, and comorbidity were investigated. There is a greater fluidity and likelihood of change in the pre-pubertal period. It was reported that the majority of affected children had been eventually developing a homosexual orientation. As an approach to determine the prevalence of GID in clinical samples in our child psychiatry clinic, screening instruments that include items on cross-gender or cross-sex identification were used. We applied the Child Behavior Checklist (CBCL). Of the 113 items in the Japanese version of the CBCL, there are two measures of cross-gender identification: "behaves like opposite sex" and "wishes to be opposite sex." Like the other items, they are scored on a 3-point scale of: 0-not true, 1- somewhat true, and 2-very true. Our study of 323 clinically-referred children aged 4-15 years reported that, among the boys, 9.6% assigned a score of 1 (somewhat true) or a score of 2 (very true) to the two items. The corresponding rates for the clinically-referred girls were 24.5%. The item of diagnosis of GID in our clinical sample was significantly higher than in non-referred children, reported as 2-5% using the same method. Two clinical case histories of screened children are also presented. Both of them were diagnosed with PDDNOS. Together with the literature review, most of the gender-related symptoms in autistic spectrum disorders (ASD) could be related to the behavioral and psychological characteristics of autism as shown in case histories. ASD subjects in adolescence can sometimes develop a unique confusion of identity that occasionally exaggerates to gender-related problems. However, these views do not explain all cases; true comorbidity of ASD and GID should be considered. A full assessment including evaluation of the family, school, and social environment is essential as other emotional and behavioral problems are very common and unresolved issues in the child's environment are often present e. g., loss. Separation problems are particularly common in the younger group. Intervention should aim to assist development, particularly that of gender identity. It should focus on ameliorating the comorbid problems and difficulties in the child's life and reducing the distress experienced by the child.

Predictors of diagnosis of child psychiatric disorder in adult-infant social-communicative interaction at 12 months

To establish which social interactive behaviours predict later psychiatric diagnosis, we examined 180 videos of a parent-infant interaction when children were aged one year, from within the Avon Longitudinal Study of Parents and Children (ALSPAC) cohort. Sixty of the videos involved infants who were later diagnosed with a psychiatric disorder at seven years, and 120 were a randomly selected sex-matched control group. Interactive behaviours for both the caregiver and the one year old infant were coded from the videos according to eight holistic categories of interpersonal engagement: Well-being, Contingent Responsiveness, Cooperativeness, Involvement, Activity, Playfulness, Fussiness, and Speech. Lower levels of adult activity and speech in interaction at one year significantly predicted overall diagnosis of child psychiatric disorder.

[Validation of the Hungarian version of the Strengths and Difficulties Questionnaire in an adolescent clinical population]

INTRODUCTION

The short Strengths and Difficulties Questionnaire (SDQ) available in parent, teacher and self-report versions, is used world-wide for assessing and screening childhood behavior and mental problems, as part of clinical assessments, therapy outcome evaluations, and research tool. The aim of the present study was to extend the use of Hungarian version to a clinical sample, to examine the clinical cut-off values suggested previously on the basis of a normative sample, and to test the questionnaire's sensitivity in differentiating between different psychiatric disorders.

METHOD

The parent and self-report versions of the five scale SDQ-Magy questionnaire was filled in by 716 parents and their children admitted to Vadaskert Child Psychiatry and Outpatient Clinic. Clinical (ICD) diagnoses were determined during psychiatric examination.

RESULTS

With a few exceptions, internal consistencies of the scales were satisfactory (0,55-0,79), the parent version showing greater reliability compared to the self-report version. Children's age, gender, and parents' level of education had some effect on the scale scores. The questionnaire's Total problem and symptom scale scores were very effective in discriminating between the control and the clinical sample. In the clinical sample, parents rated their children's behavior and mental problems as more severe. Profiles of scale scores distinguished the wider internalizing, externalizing, and co-morbid diagnostic categories, as well as the eight specific diagnoses. Based on the normal-abnormal cut-off values proposed earlier (Turi et al., 2011), the great majority of clinical cases were screened by the questionnaire.

CONCLUSIONS

The Hungarian version of the SDQ proved applicable in a clinical sample. Psychometric properties, variances due to age, gender and informant were consistent with international experiences. SDQ profiles related to clinical diagnoses and their difference from the control group show the sensitivity and discriminative power of the questionnaire, while the screening ability based on clinical cut-offs also supports the clinical use of the questionnaire.

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.

Annual research review: re-thinking the classification of autism spectrum disorders

BACKGROUND

The nosology of autism spectrum disorders (ASD) is at a critical point in history as the field seeks to better define dimensions of social-communication deficits and restricted/repetitive behaviors on an individual level for both clinical and neurobiological purposes. These different dimensions also suggest an increasing need for quantitative measures that accurately map their differences, independent of developmental factors such as age, language level and IQ.

METHOD

Psychometric measures, clinical observation as well as genetic, neurobiological and physiological research from toddlers, children and adults with ASD are reviewed.

RESULTS

The question of how to conceptualize ASDs along dimensions versus categories is discussed within the nosology of autism and the proposed changes to the DSM-5 and ICD-11. Differences across development are incorporated into the new classification frameworks.

CONCLUSIONS

It is crucial to balance the needs of clinical practice in ASD diagnostic systems, with neurobiologically based theories that address the associations between social-communication and restricted/repetitive dimensions in individuals. Clarifying terminology, improving description of the core features of ASD and other dimensions that interact with them and providing more valid and reliable ways to quantify them, both for research and clinical purposes, will move forward both practice and science.

Comparison of ICD-10 and DC: 0-3R diagnoses in infants, toddlers and preschoolers

The purpose of this study was to analyze and compare diagnoses of patients from a special outpatient department for infants, toddlers and preschoolers. Specifically, overlap, age and gender differences according to the two classification systems DC: 0-3R and ICD-10 were examined. 299 consecutive children aged 0-5; 11 years received both ICD-10 and DC: 0-3R diagnoses. All ICD-10 diagnoses were given prospectively at the initial contact. The DC: 0-3R diagnoses were allotted in mutual consensus conferences. The most common ICD-10 disorders were Oppositional Defiant (ODD), Hyperkinetic (HKD) and Emotional Disorders. In DC: 0-3R, nearly half of the children could not be coded adequately ('Other Disorders'). Sleep Behavior Disorders were followed by Feeding Behavior and Regulation Disorders. Both classification systems are needed in infant, toddler and preschool psychiatry. There is a good concordance of the two systems for Feeding, Sleeping, Adjustment and Attachment Disorders, whereas the ICD-10 diagnoses HKD and ODD are not adequately represented in DC: 0-3R.

The validity of psychiatric diagnoses: the case of 'specific' developmental disorders

We tested whether developmental coordination disorder (DCD) and mixed receptive expressive language disorder (RELD) are valid diagnoses by assessing whether they are separated from each other, from other childhood disorders, and from normality by natural boundaries termed zones of rarity. Standardized measures of intelligence, language, motor skills, social cognition, and executive functioning were administered to children with DCD (n = 22), RELD (n = 30), autistic disorder (n = 30), mental retardation (n = 24), attention deficit/hyperactivity disorder (n = 53) and to a representative sample of children (n = 449). Discriminant function scores were used to test whether there were zones of rarity between the DCD, RELD, and other groups. DCD and RELD were reliably distinguishable only from the mental retardation group. Cluster and latent class analyses both resulted in only two clusters or classes being identified, one consisting mainly of typical children and the other of children with a disorder. Fifty percent of children in the DCD group and 20% in the RELD group were clustered with typical children. There was no evidence of zones of rarity between disorders. Rather, with the exception of mental retardation, the results imply there are no natural boundaries between disorders or between disorders and normality.

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.

Therapeutic uses of the WebCam in child psychiatry

OBJECTIVE

The authors provide examples for the use of the WebCam as a therapeutic tool in child psychiatry, discussing cases to demonstrate the application of the WebCam, which is most often used in psychiatry training programs during resident supervision and for case presentations.

METHOD

Six cases illustrate the use of the WebCam in individual and family therapy.

RESULTS

The WebCam, used during individual sessions, can facilitate the development of prosocial skills. Comparing individual WebCam video sessions can help to evaluate the effectiveness of medication and progress in therapy.

CONCLUSION

The WebCam has proven to be useful in psycho-education, facilitating communication, and treating children and families. The applications of this technology may include cognitive-behavioral therapy, dialectical-behavioral, and group therapy.