Personality, delinquency, and criminal recidivism

This study explores the relationship between PEN profiles, delinquency, and recidivism in young offenders. According to Eysenck, personality is based on three basic Dimensions: Psychoticism, Extraversion, and Neuroticism (PEN-model). Eysenck states that delinquents score high on all three dimensions. A group of young male offenders in a juvenile detention center in The Netherlands were studied to test Eysenck's hypothesis, which was partially confirmed. From a cluster analysis it appear that only a small group of offenders had high scores on all three PEN dimensions. Finally, it was concluded that the PEN profiles were not able to differentiate between recidivists and nonrecidivists.

Child and adolescent psychiatrists' practices in assisting their adolescent patients who smoke to quit smoking

OBJECTIVE

This national study examined the practices and perceptions of smoking cessation activities among child and adolescent psychiatrists.

METHOD

A random sample of child and adolescent psychiatrists was identified from the membership list of the American Academy of Child and Adolescent Psychiatry and was mailed a valid and reliable 34-item questionnaire.

RESULTS

A total of 184 responses (47%) were received. A plurality (48%) of psychiatrists reported being self-taught in smoking cessation techniques. A majority (67%) of psychiatrists were in the maintenance stage for asking about smoking status. However, only 19% consistently made attempts to assess willingness to quit, and 30% consistently gave messages urging the smoker to quit. The perceived number of barriers for addressing smoking was negatively correlated with psychiatrists' levels of confidence (r = -0.35, p <.001) and preparedness (r = -0.39, p <.001) in addressing smoking cessation. Estimations by the psychiatrists of youths who smoked were 61% of those with conduct disorders, 46% of those with schizophrenia, and 40% of those with attention-deficit/hyperactivity disorder.

CONCLUSION

Considering the perceived high rate of patient smoking and the lack of formal training in smoking cessation, more postgraduate education is needed to adequately prepare child and adolescent psychiatrists for addressing tobacco cessation.

ICD-10 classification in Danish child and adolescent psychiatry--have diagnoses changed after the introduction of ICD-10?

The aim was to test this in a nationwide register study of diagnoses used in child and adolescents psychiatry in Denmark. A larger number of different diagnoses were expected to be applied after the introduction of the 10th version of the International Classification of Diseases (ICD-10). Reflecting the time trend, we particularly expected an increase in the number of neuropsychiatric diagnoses. From the Danish Psychiatric Central Register data were drawn on clinical discharge diagnoses. All patients aged 0-15 years examined at psychiatric hospitals from 1995-2002 were included; 22,469 children and adolescents with a first contact were registered. The most frequent discharge diagnoses were pervasive development disorders (PDD; 11.9%), adjustment disorders (10.6%), conduct disorder (9.5%), emotional and anxiety disorders (7.6%), hyperkinetic disorders (7.3%), and specific developmental disorders (7.3%). We found a significant increase in the number of neuropsychiatric and affective diagnoses and a significant decrease in the number of adjustment, conduct and anxiety diagnoses during the study period. Of the 22,469 diagnoses, 45% were only partly specified according to ICD-10. Thirty-four per cent had diagnoses unspecified on the four-character level (Fxx.9) and 11% had Z-diagnoses. A larger number of different diagnoses and an increase in the use of neuropsychiatric diagnoses were seen after the introduction of ICD-10. Many diagnoses were only partly specified; consequently, a more detailed specification of the ICD-10 is still required.

[Child and adolescent psychiatry: a profession and its identity II]

BACKGROUND

Up till the 1970s child and adolescent psychiatry had no distinctive diagnostic system of its own. From the 1980s onwards qualitative information-gathering (e.g. via discussion or play-situations) was no longer regarded as adequate and the standardised gathering of (quantitative) information became the cornerstone of the diagnostic process. This development fundamentally changed the child psychiatrist's profession and its identity.

AIM

To investigate the specific features that are required in current child and adolescent psychiatry.

METHOD

In this article we will clarify the change in the child psychiatrist's profession and identity by outlining how child an adolescent psychiatry evolved as from the early 1980s. We will do this by concentrating on the diagnostic process. The treatment aspect will be discussed only briefly.

RESULTS

Over the last 25 years the role of the child psychiatrist has undoubtedly changed. From being mainly a diagnostician and/or being personally responsible for treating the child or adolescent the child psychiatrist has become increasingly the person who controls the diagnostic process and plans treatment.

CONCLUSION

Over the last two decades the diagnostic technique of the child psychiatrist has developed in a new direction. The child psychiatrist has chosen instead to elucidate a patient's referral and to discuss the reasons for a request for assistance and/or care. The psychiatrist uses many types of information and a multitude of informants and methods. This development has led to a fundamental change in the child psychiatrist's profession and its identity.

Innovations: child & adolescent psychiatry: Training in developmental responses to trauma for child service providers

Youths most at risk of exposure to community violence are often those who are least likely to receive the attention of mental health professionals. The column describes the development and testing of training about trauma for school personnel and other community providers of children's services. The curriculum was developed with input from focus groups of school nurses. The one-day training sessions address nine areas: normal responses to stress, abnormal responses to stress, posttraumatic stress disorder and acute stress disorder, stage theories of loss and grief, risk and protective factors, crisis and disaster planning, resilience, mental health referral sources, and self-care techniques.

Innovations: child and adolescent psychiatry: measuring outcomes of real-world youth psychotherapy: whom to ask and what to ask?

To illustrate complexities in outcomes measurement for youths receiving community-based mental health services, this column presents data on 112 youths in publicly funded, usual-care psychotherapy. Youths and their parents separately completed standard measures of outcomes in three domains--symptoms, functioning, and family environment--at baseline and at six months. The results indicate minimal agreement between youths and parents on individual outcome domains and almost no overlap for each informant (youth and parent) across multiple domains. These findings are especially relevant because service providers are increasingly required to demonstrate treatment effectiveness and monitor youths' progress. The results highlight the complexities in measuring the impact of care and indicate the need to develop more feasible methods to measure multidimensional outcomes.

The community intensive therapy team: development and philosophy of a new service

The Community Intensive Therapy Team (CITT) has been operating since 1998. It was developed to cater for the needs of patients with complex difficulties referred to a specialist Child and Adolescent Health Service (CAMHS) in South Wales, UK. The patients served by the CITT are comparable with patients who might be referred for admission to an inpatient unit and include patients with eating disorders, psychosis, affective disorders, adjustment disorders or repetitive self-harm. The theoretical model used is based on a biopsychosocial model which aims to empower and support family members. The philosophy of the CITT is to work with the child and family in their own environment, tailoring the therapy to the needs of all concerned. CITT makes use of the strengths within the patient, the family and extended family, the agencies already involved and the environment. Since its introduction, the CITT has been able to manage all the complex referrals made to it from the generic Tier 2/3 CAMHS teams it serves, with minimal recourse to inpatient beds.

Psychological testing in adolescent medicine

Psychological and neuropsychological assessment remains an important aspect of clinical evaluation in adolescents with psychiatric and neurologic disorders. The primary care practitioner can refer for psychological and neuropsychological assessment when cognitive, behavioral, or psychiatric problems appear to be affecting the adolescent's learning, psychosocial development, or overall functioning. The most appropriate assessment depends upon the diagnostic issue at hand. Most referrals will include IQ and achievement testing to assess for learning disabilities; behavioral and personality assessment to aid in psychiatric diagnosis and treatment planning; and neuropsychological testing for more complex issues, such as the impact of neurological disorders and injuries on cognition and behavior. The patient can be referred to the school psychologist for IQ and achievement testing that complements any additional testing that may be required to help determine the best intervention. Psychological assessment can be invaluable in the early identification and intervention of learning, behavioral, and psychiatric difficulties in adolescents.

Disruptive behaviors: conduct and oppositional disorders in adolescents

CD and ODD present unique challenges in both the diagnostic and treatment arenas. The complex network of causes leading to disruptive disorders makes it necessary to structure treatment in a multifaceted manner. The earlier that adolescents are identified as exhibiting disruptive behavior disorders, the better the opportunity to intervene. While early-onset CD is very difficult to treat effectively, the disorder is far more difficult to correct if left untreated and can ultimately lead to ASPD in adulthood. When physicians are presented with behavioral complaints, they must fully assess the adolescent to determine what, if any, referrals and treatments are needed.

Staff views of a deliberate self-harm protocol for children and young people

An audit to evaluate a protocol for the management of children and young people presenting with self-harm was undertaken at Calderdale and Huddersfield NHS Trust. The objectives were to review current practice and to identify strengths and challenges. The audit showed that most staff were aware of the written procedure for obtaining a specialist assessment by the child and adolescent mental health services (CAMHS), but that feedback was inconsistent and there was a need for improved communication between health professionals.

Psychiatric emergencies in adolescents

The spectrum of psychiatric emergencies in adolescents may be best appreciated using the broad framework of urgency. ED physicians and staff using such a framework will be in a better position to triage and to tailor the evaluation assessment and target the intervention and disposition. Understanding the range of urgency can minimize frustration, enhance the clinician's ability to accurately assess complex situations, and make a tremendous difference in the patient's receipt of future services. This article reviews the epidemiology, risk factors, and critical elements of emergency evaluation and treatment of a variety of juvenile psychiatric emergencies. Factors influencing presentation, disposition,and consideration of local treatment resources are reviewed.

Disorders of mood and anxiety in adolescents

Mood disorders and anxiety disorders contribute significantly to morbidity and mortality during adolescence. These disorders often persist or recur in adulthood. Clinical presentations in the primary care setting are myriad and often confusing. Early recognition, differentiation from physical and other psychiatric disorders, and accurate diagnosis lead to more appropriate treatment and improved outcome. Collaboration among primary care providers and mental health professionals is key to reducing the suffering from these disorders for adolescents and their families.

Psychopharmacology in adolescent medicine

Psychopharmacology is a challenge for health care providers treating adolescents. A detailed and accurate assessment, including developmental issues relevant to adolescence in general and to the individual adolescent, guides clinicians in formulating thoughtful and effective treatment plans to meet the needs of each patient. Parents play an important role in providing family history regarding psychiatric diagnoses and the response to various drugs, in making decisions to initiate medication and to change a medication regimen, and in monitoring an adolescent's adherence to a prescribed regimen. The role of parents is especially important for younger patients. Following the biopsychosocial model, rarely should psychopharmacologic agents be used as the sole means to treat a psychiatric condition in adolescents. Pharmacologic agents described in this article are tools that have their effect in the biological domain of central neurotransmitters, but psychosocial interventions addressing the emotional and behavioral issues that are the indications for such medication are generally also required. The development of newer medications holds promise for more effective treatment of target symptoms with minimal side effects.

Psychosis in adolescence

Psychotic behavior in adolescent patients is uncommon but occasionally encountered in adolescent medicine practice. Although a physician may not be able to distinguish the precise diagnosis initially, immediate symptomatic management of acute psychotic symptoms is indicated to allay the patient's anxiety and tQ begin treatment. In chronic and more subtle conditions, their recognition is the essential first step. In all cases, referral to a mental health specialist is indicated for comprehensive evaluation and appropriate management. Continuing support of patient and family by the primary care physician avoids a perception of abandonment and can help ensure effective long-term care.

Innovations: Child & adolescent psychiatry: "Sweet are the uses of adversity": a transition program for children discharged from an inpatient unit

A planning and implementation group was created to respond to a severe shortage of public-sector children's inpatient beds in New Orleans. This group identified a large gap in the continuum between the inpatient unit, with its wide range of resources, and the five traditional mental health centers that provided medication management as well as social work contacts on a weekly to monthly basis. A unique "transition program" was created that has effectively bridged the gap between the hospital and the rest of the community. Data on the program, including clinical functioning data, improvement and severity ratings, data on recidivism, aftercare compliance ratings, and satisfaction surveys, have demonstrated that the program had a positive impact.

School-Based Intervention for Adolescents with Social Anxiety Disorder: Results of a Controlled Study

Social anxiety disorder, whose onset peaks in adolescence, is associated with significant impairment. Despite the availability of effective treatments, few affected youth receive services. Transporting interventions into schools may circumvent barriers to treatment. The efficacy of a school-based intervention for social anxiety disorder was examined in a randomized wait-list control trial of 35 adolescents (26 females). Independent evaluators, blind to treatment condition, evaluated participants at preintervention, postintervention, and 9 months later. Adolescents in the intervention group demonstrated significantly greater reductions than controls in social anxiety and avoidance, as well as significantly improved overall functioning. In addition, 67% of treated subjects, compared to 6% of wait-list participants, no longer met criteria for social phobia following treatment. Findings support the possible efficacy of school-based intervention for facilitating access to treatment for socially anxious adolescents.

Selective serotonin reuptake inhibitors for children and adolescents with major depression: current controversies and recommendations

Recent warnings about potential serious adverse effects with the selective serotonin reuptake inhibitors in children and adolescents with depression raises questions about the risk-benefit ratio of these drugs in this population. Published safety and efficacy trials of SSRIs for the treatment of youth with depression are critically reviewed. These data were augmented by information from regulatory hearings in 2003-2004 and selected open-label reports. Based on this review, recommendations for medication treatment and monitoring of children and adolescents with major depression on SSRIs are provided. Emerging data from several clinical trials show that the SSRIs provide moderate benefits for youth with depression. In addition, SSRI treatment may be associated with increased risk of behavioral activation, self-harm, and suicidal ideation. Appropriate use of the SSRIs in children and adolescents requires careful diagnostic assessment, evaluation of comorbidity, and close monitoring, especially early in treatment.

Using and teaching evidence-based medicine: the Duke University child and adolescent psychiatry model

Evidence-based medicine (EBM) is defined as a set of processes that facilitate the conscientious, explicit, and judicious integration of individual clinical expertise with the best available external clinical evidence from systematic research in making decisions about the care of individual patients. EBM focuses not only on grading the strength of the evidence but also on the processes and tools that are necessary for clinicians to continually upgrade their knowledge and skills for those problems encountered in daily practice. This article, authored by members of the Duke Pediatric Psychiatry EBM Seminar Team, (1) describes EBM as applied to the training of child and adolescent psychiatrists in the Division of Child and Adolescent Psychiatry, Department of Psychiatry at Duke University Medical Center; (2) presents a simplified discussion of EBM as a technology for training and patient care; (3) discusses the basic principles and procedures for teaching EBM in the setting of a multidisciplinary training program; and (4) briefly mentions two training and research initiatives that are furthered by incorporating EBM.

Promoting the implementation of practices that are supported by research: the National Implementing Evidence-Based Practice Project

The National Implementing Evidence-Based Practice Project is an ongoing effort to promote the implementation of effective practices for adults who have severe mental illnesses. The project members designed and developed integrated packages of materials and services to help practice sites implement evidence-based practices and is field-testing the approach in eight states. These implementations are being evaluated carefully to learn how to make the technology transfer process more efficient in the future. This article describes the project and provides some early reflections on the implementation experience.

Measuring Provider Attitudes Toward Evidence-Based Practice: Consideration of Organizational Context and Individual Differences

Mental health provider attitudes toward adoption of innovation in general and toward evidence-based practice (EBP) in particular are important in considering how best to disseminate and implement EBPs. This article explores the role of attitudes in acceptance of innovation and proposes a model of organizational and individual factors that may affect or be affected by attitudes toward adoption of EBP. A recently developed measure of mental health provider attitudes toward adoption of EBP is described along with a summary of preliminary reliability and validity findings. Attitudes toward adoption of EBP are discussed in regard to provider individual differences and the context of mental health services. Finally, potential applications of attitude research to adoption of EBP are discussed.

Theories related to changing clinician practice

This article provides a theoretic exploration of the microprocesses of clinician practice change in the context of adopting and implementing evidence-based treatments. The two most important internal clinician or microlevel factors involved in behavior change are identified as motivation and ability. The authors focus on factors related to motivation and present their own theory of the cognitive-affective processes for motivation to change. In the discussion of their theory, the authors highlight leverage points for possible interventions. Finally, the authors show how their microlevel theory relates to other prominent, more macrolevel-oriented theories of clinician practice change.