AACAP 2005 Research Forum: speeding the adoption of evidence-based practice in pediatric psychiatry

OBJECTIVES

At the 2005 Annual Meeting of the American Academy of Child and Adolescent Psychiatry (AACAP), the Academy's Workgroup on Research conducted a Research Forum entitled "Increasing Research Literacy Through the Adoption of Evidence-Based Practice (EBP) in Pediatric Psychiatry."

METHOD

Forum participants focused on speeding the adoption of EBP across five areas: EBP as the preferred heuristic for teaching research literacy, use of EBP in training programs, dissemination of EBP in clinical practice, EBP in partnership with industry, and EBP as a framework for developing practice guidelines.

RESULTS

EBP provides an easy-to-understand method for accessing and evaluating the research literature and then applying this information to decisions about patient care. Although EBP has been gaining greater visibility in pediatric psychiatry, it is far from the preferred heuristic. To move the field toward fully embracing EBP will require greater understanding of what EBP is (and is not), educating mental health professionals in EBP skills, access to EBP resources, and a commitment to apply EBP to the conceptualization and design of research protocols and practice guidelines.

CONCLUSIONS

Pediatric psychiatry would benefit from a principled commitment to follow other areas of medicine in adopting EBP.

Survey of atypical antipsychotic prescribing by Canadian child psychiatrists and developmental pediatricians for patients aged under 18 years

OBJECTIVE

To describe self-reported patterns of prescribing atypical antipsychotics (ATAs) and monitoring practices of child psychiatrists and developmental pediatricians in Canada.

METHOD

We surveyed members of the Canadian Academy of Child and Adolescent Psychiatry and members of the Developmental Paediatrics Section of the Canadian Paediatric Society regarding the types and frequencies of ATAs they prescribed, the ages and diagnoses of patients for whom they prescribed these medications, and the types and frequencies of monitoring used.

RESULTS

Ninety-four percent of the child psychiatrists (95% CI, 90% to 97%) and 89% of the developmental pediatricians (95% CI, 75% to 96%) prescribed ATAs, most commonly risperidone (69%). Diagnoses included psychotic, mood, anxiety, externalizing, and pervasive developmental disorders. Prescribing for symptoms such as aggression, low frustration tolerance, and affect dysregulation was also common. Twelve percent of all prescriptions were for children under age 9 years. Most clinicians monitored patients, but there were wide variations in the type and frequency of tests performed.

CONCLUSIONS

Despite the lack of formal indications, ATAs were prescribed by this group of clinicians for many off-label indications in youth under age 18 years, including very young children. Neither evidence-based guidelines nor a consensus on monitoring exist for this age group.

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.

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.

Consensus report on impulsive aggression as a symptom across diagnostic categories in child psychiatry: implications for medication studies

OBJECTIVE

To determine whether impulsive aggression (IA) is a meaningful clinical construct and to ascertain whether it is sufficiently similar across diagnostic categories, such that parallel studies across disorders might constitute appropriate evidence for pursuing indications. If so, how should IA be assessed, pharmacological studies designed, and ethical issues addressed?

METHOD

Experts from key stakeholder communities, including academic clinicians, researchers, practicing clinicians, U.S. Food and Drug Administration, National Institute of Mental Health, industry sponsors, and patient and family advocates, met for a 2-day consensus conference on November 4 and 5, 2004. After evaluating summary presentations on current research evidence, participants were assigned to three workgroups, examined core issues, and generated consensus guidelines in their areas. Workgroup recommendations were discussed by the whole group to reach consensus, and then further iterated and condensed into this report postconference by the authors.

RESULTS

Conference participants agreed that IA is a substantial public health and clinical concern, constitutes a key therapeutic target across multiple disorders, and can be measured with sufficient precision that pharmacological studies are warranted. Additional areas of consensus concerned types of measures, optimal study designs, and ethical imperatives.

CONCLUSION

Derived from scientific evidence and clinical experience, these consensus-driven recommendations can guide the design of future studies.

Attachment Theory and Reactive Attachment Disorder: Theoretical Perspectives and Treatment Implications

TOPIC

Attachment theory and reactive attachment disorder (RAD).

PURPOSE

To highlight current perspectives on attachment theory, RAD, and treatment implications using a case study of an 8-year-old patient with RAD.

SOURCES

Selected multidisciplinary literature related to attachment theory and RAD.

CONCLUSIONS

The literature provides a body of work that substantiates the importance of early attachment relationships to human development and highlights gaps in our knowledge related to treatment of children with RAD. The quality of early attachment relationships is correlated with future personality and brain development. Attachment disturbances are associated with psychopathology in childhood and adulthood. Although evidence for the effective treatment of children with attachment disorders is minimal and inconclusive, the two major perspectives, developmental psychology and neuropsychoanalysis, offer guidelines for practice.

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.

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.

[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.

Effective communication with bereaved child survivors of suicide

TOPIC

While bereavement is considered by many to be among the most stressful life events, it becomes even more distressing when it is related to the suicide of a loved one. Further, the death of a parent is traumatic for anyone, but it may be especially intensified for young children. This points to a strong need for the recognition and treatment of psychiatric and social problems associated with childhood bereavement.

PURPOSE AND SOURCES

The purpose of this paper is to review the literature and present a synopsis of the psychosocial outcomes of childhood suicide survivor bereavement and outline communication issues that emerge when talking with young suicide survivors.

CONCLUSIONS

A case is made to develop and test interventions designed to meet the mental health needs of this important group of individuals.

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.

Using projective techniques in the evaluation of groups for children of rehabilitating drug addicts

Evaluators and researchers often have to deal with situations in which conventional research tools are impossible to use, either because of the characteristics of a population or unclear research variables. This paper presents a technique that succeeds in overcoming this kind of problem--a projective technique, but one that differs from the usual approach to projective techniques. The approach presented here is a hermeneutic one that assumes an interpretive process. By means of an example, this paper presents the process of working with projective techniques and concludes with a discussion of this approach.

Views of child psychiatrists on physical contact with patients

The appropriateness and therapeutic value of physical contact with children is under increasing scrutiny. We conducted a postal questionnaire and telephone survey of consultant child and adolescent psychiatrists within Great Britain to investigate attitudes of specialists towards physical contact with their patients in different clinical contexts. Here we report that psychiatrists tend to restrict physical contact to the minimum essential for patient comfort or safety. Decision-making about contact is primarily influenced by professional experience and training. This conservative approach to physical contact with patients has implications for clinical practice and requires to be better informed by evidence.

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.

[Prescription of psychotropic drugs in paediatry: approved indications and therapeutic perspectives]

In France, psychotropic drugs may be classified in four categories according to their official data. The first category corresponds to psychotropic drugs with an approved indication available in paediatry. Theyare old agents (e.g. haloperidol, amitriptyline, benzodiazepines...) with the exception of methylphenidate (hyperactivity). The second one corresponds to pharmacological agents approved for some indications obtained with adults but not for a1l (i.e. restricted indication: e.g. sertraline approved in paediatry only for OCD but not for depression, risperidone approved only for the treatment of disruptive behaviors in children with subaverage IQs). For the third category, the psychotropic agent is either contraindicated or unadvised under the age of 15 or 18 years, by lack of data (e.g. most of SSRI or atypical antipsychotic drugs). For the last category, official data available in brief summaries offer no information on paediatric use and consequently their administration does not appear possible. Up to now, no approved use has been delivered to injection route (IM or IV) in France, except for an IM formulation of zuclopenthixol. Prescribing psychotropic drug has to respect good practices including close psychological and somatic monitoring that associates the young patient and his relative (psycho-education program). Particular key-points should be taken into consideration (i.e. pharmacokinetic and physiological specificities, risk of false passage under the age of 6 years with capsules or tablets, presence of alcohol in some oral solution or bitter aroma...). Beside these official data, many studies have been published but must be carefully interpreted according to their level of pertinence. Meta-analysis gather all randomised controlled trials published or not, analyse their specific pertinence and thus provide clinically relevant elements. Randomised controlled trials present clinical interest but key-points in study design must be checked (e.g. number of patients, inclusion and exclusion criteria, length of the study and clinical relevance of clinical scales...). Other studies like open trials or clinical cases do not offersufficient guarantees. Some randomised controlled trials of clinical relevance have been carried out in this population with new pharmacological classes (eg SSRI, atypical antipsychotic drugs) and may lead to extended indications in children and adolescents. According to bibliographic and official data, the main criteria in the prescribing choice may take into consideration the following sis stressing a poor benefit/risk ratio. SSRI may offer better prospects but their use has not been approved in this indication, until now. In OCD, sertraline shows great interest to enhance clinical response and represents the molecule of reference. No drug has been approved for mood disorders in children or adolescent, in France, contrary to USA where lithium can be administered over the age of 12 years. In addition, antiepileptic drugs like carbamazepine or divalproate have conducted to clinical improvement in some studies. Benzodiazepines, hydroxyzine and meprobamate use should be strictly restricted in case of anxiety symptoms but are the only agents approved in this indication despise promising results obtained with SSRI. Transitory insomnia may take advantage of alimemazine prescription (approved use over the age of 36 months). Some typical neuroleptics are indicated in tics or in behaviour disorders associated to autism or related syndromes but present clinical limitations and poor tolerability. Promising clinical trials (randomised or not) have been conducted with new atypical antipsychotic drugs like risperidone. In conclusion, present data available for paediatric use of psychotropic agents emphasizes that safety and effectiveness are not always well established in particular for the treatment of chronic disorders (long term tolerability assessment). Moreover, studies should be carried out to specify factors promoting adherence and quality of life for this young population in order to optimise clinical benefit of drug prescription.

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.