Diagnostic profiles in outpatient child psychiatry

Outpatient child psychiatrists appear to be treating a broadening array of complex, highly comorbid, and difficult-to-treat youths. In this study, designed to evaluate the current demographic and diagnostic profile of outpatient child psychiatric patients 1,292 outpatient records from 8 treatment settings were reviewed. Patient age, race, gender, and diagnoses were recorded and analyzed. Externalizing disorders (ADHD and/or behavior disorders) were diagnosed most frequently, followed by internalizing (depressive and anxiety) disorders. Comorbidity was evident in nearly half of all patients, regardless of age. Substance abuse was infrequently reported as a comorbid condition. Externalizing and internalizing pathology frequently co-occurred. Findings reinforce the need for clinician vigilance and thorough assessment of outpatient children and adolescents.

Using the science fiction film invaders from Mars in a child psychiatry seminar

OBJECTIVE

The science fiction film Invaders From Mars is used to teach principles of child development; clinical features of separation anxiety and nightmares; and clinical interventions, including child psychotherapy, child protective issues, and crisis management.

METHODS

Commercial films have been used as teaching aids in child psychiatry seminars. In this child psychiatry seminar, Invaders From Mars is viewed, and relevant teaching points are discussed with child psychiatry residents.

RESULTS

The response of child psychiatry residents has been positive, with high ratings.

CONCLUSION

This film may serve as a useful tool for teaching child psychiatry residents principles of child development, clinical features of separation anxiety and nightmares, and basic clinical interventions.

Media outreach for child psychiatrists

Psychiatrists have mixed feelings about working with the mass media. There are many reasons to respond to reporters or proactively reach out to the media, including reducing stigma and other barriers to seeking and complying with treatment and counteracting media misinformation and distortion. This article addresses ways to increase positive outcomes when psychiatrists respond to calls from reporters, make proactive efforts to influence behaviors or policies, or take advantage of breaking news to educate reporters and the public. The article also reviews examples of planned media campaigns.

Medical decision making: a selective review for child psychiatrists and psychologists

Physicians, including child and adolescent psychiatrists, show variability and inaccuracies in diagnosis and treatment of their patients and do not routinely implement evidenced-based medical and psychiatric treatments in the community. We believe that it is necessary to characterize the decision-making processes of child and adolescent psychiatrists using theories and methods from cognitive and social sciences in order to design effective interventions to improve practice and education. This paper selectively reviews the decision-making literature, including recent studies on naturalistic decision making, novice-expert differences, and the role of technology on decision making and cognition. We also provide examples from other areas of medicine and discuss their implications for child psychiatry.

Using Dance/Movement Therapy to Augment the Effectiveness of Therapeutic Holding with Children

PROBLEM

Therapeutic holding is a commonly used tool for the containment of aggressive behavior in children. Although often effective, the intervention has inherent physical and emotional safety risks. Can a body-based therapy be used to limit these risks?

METHODS

Research was conducted incorporating dance/movement therapy techniques (D/MT) before and after therapeutic holding to investigate this question. Volunteer residential treatment center staff participated in a 4-hour D/MT-based training workshop integrating the techniques with the intervention. Children participated via self-report.

FINDINGS

D/MT training increased adult awareness, sensitivity, perspective shifting ability, and confidence in the intervention while decreasing the necessity for physicality.

CONCLUSION

Integrating D/MT therapy training with therapeutic holding decreased the threat of trauma to adult participants. Further research into the integration of D/MT techniques with safe holding procedures may prove helpful in the challenge of making restraints safer for both children and adults.

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.

Family perspectives on evidence-based practice

The focus on evidence-based practices has come to dominate discussions in medicine and mental health. Whereas professionals and providers focus on complex barriers to implementing and engaging administrative support, the realities for families are different. The mental health system in most communities is still fragmented and inaccessible, leaving parents overwhelmed and frustrated. To truly implement system reform, the practical needs and experiences of families must become a key strategic element.

Practitioner perspectives on evidence-based practice

Most aspiring child mental health professionals would support the premise that clinical practice should have a scientific foundation. Why, then, is the implementation of evidence-based practice in child and adolescent psychiatry so difficult? Considering the multiple stakeholders in clinical work, impediments are not surprising. Practitioner delays in implementation of research findings are common to all specialties of medicine. This article outlines the barriers to implementation of evidence-based practice and suggests changes to motivate and enable clinicians to use evidence-based practices.

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.

Reactive and proactive aggression in children--a review of theory, findings and the relevance for child and adolescent psychiatry

The clinical population of aggressive children diagnosed as having an oppositional defiant disorder (ODD) or a conduct disorder (CD) is heterogeneous, both with respect to behaviour and aetiology. Recently, the following distinction has been proposed that might further clarify this heterogeneity: reactive aggression is an aggressive response to a perceived threat or provocation, whereas proactive aggression is defined as behaviour that anticipates a reward. In this article we examine various aspects of this distinction. We will [1] examine the evidence that reactive and proactive aggression are distinct phenomena by discussing the theories underlying the distinction between the subtypes in humans and we briefly review evidence for a similar distinction in animals; [2] we critically review the literature on the measurement in children via questionnaires and behavioural observations; we then point out that the correlation observed between the subtypes is due to the fact that many children show both types of aggression; [3] we review the literature on specific characteristics of the subtypes giving attention to social information processing, peer status, biological correlates and developmental history, and demonstrate that there is some evidence to suggest that reactive and proactive aggression are distinct dimensions; [4] we discuss the relevance of the distinction between reactive and proactive aggression for child and adolescent psychiatry.

An interview with Michael Fordham

In the course of early interviews on the history of psychoanalysis, I saw Michael Fordham in the late summer of 1965. We concentrated primarily on the differences between Freud and Jung, as well as the characteristic distinctions between the two schools that they founded. Fordham also talked about some of his personal contacts with Jung.

Improving GPs' skills and competencies in child psychiatry

Concerned at the poor availability of psychiatric services for children and adolescents, the Finnish Parliament allocated extra funds for their development during 2000 and 2001. With this subsidy, a project was set underway to update general practitioners' (GPs') skills and knowledge in child psychiatry. The problem-based learning (PBL) method was used, combined with multidisciplinary teamwork. The present paper reports on changes Finnish GPs' perceptions of their knowledge and skills in child psychiatry over a 1-year period. The study sample comprised 761 physicians working in health centres in the area of Tampere University Hospital, with a catchment population of one million. GPs' self-assessments of their skills in child psychiatry in 16 areas were collected by postal questionnaire in 2000 and 2001. The response rates were 66.1% and 57.1%, respectively. Those who answered in both years were included in the analysis (n=371). Some GPs felt that their skills and competencies had improved and some that they had declined, while the majority reported no changes. According to logistic regression analysis, the only factor explaining a marked positive change was participation in child psychiatric training. In two areas of competence, GPs who had attended child psychiatric training rated their skills as significantly better than those who had not attended such training. We conclude that the effect of this undertaking was modest when implemented as a one-off training event.

Translating child analysis from the playroom to the classroom: opportunities and choices

Over the years, psychoanalysts and educators have made efforts to meld a psychoanalytic orientation with the education of young children. The resulting programs have variously been called psychoanalytic nurseries, therapeutic nurseries, therapeutic preschools, or psychoanalytic early childhood programs. The methodology of the application or integration of psychoanalysis with the education of young children has received relatively little attention. After a brief historical review of the application of psychoanalysis to helping children in group educational settings, a number of features common to programs integrating psychoanalysis and early childhood education are described. A specimen program is next presented in which an application of psychoanalysis is used to assist children whose development is proceeding in a psychopathological direction. Also demonstrated are various ways in which psychoanalysis may be adapted to such programs, some options involved, and the capacity, realized and potential, for work within a therapeutic nursery to expand the field of inquiry and the therapeutic action of child analysis as conducted within a traditional framework.

EINAQ -- a European educational initiative on Attention-Deficit Hyperactivity Disorder and associated problems

BACKGROUND

Continuing Medical Education (CME) plays an important role in quality management, especially as quality assurance, for the improvement of healthcare in child and adolescent psychiatry. This requires responsibility regarding quality standards of clinical practice throughout Europe as outlined by the European Union of Medical Specialists (UEMS).

OBJECTIVE

Therefore, steps should be undertaken to improve specialists' medical care and harmonize it in Europe. Attention-Deficit Hyperactivity Disorder (ADHD) with its many co-existing developmental disorders/problems is the central healthcare problem in child and adolescent psychiatry with high impact on society. Therefore, it was chosen as the target.

METHOD

A European Interdisciplinary Network for ADHD Quality Assurance (EINAQ) was founded, didactic material was developed and a faculty of experts from several European countries established to offer all over Europe harmonized courses on ADHD and associated problems.

RESULTS

Pilot courses were given in Germany in 2003/2004 and were highly appreciated by the participants. Further courses in Germany and other European countries will take place in 2004.

CONCLUSION

EINAQ seems to be on the right track to be part of CME and specialized networks for healthcare in ADHD to improve the provision for mental health problems in children and adolescents in Europe. Cooperative projects with official European bodies like the UEMS -- Section on Child and Adolescent Psychiatry/Psychotherapy and the European Society of Child and Adolescent Psychiatry could strengthen the impact of EINAQ.

Do child psychiatrists in Germany diagnose bipolar disorders in children and adolescents? Results from a survey

OBJECTIVES

There is a controversy about the prevalence of childhood bipolar disorders (BD). Based on discrepant results, we studied if German psychiatrists in outpatient settings diagnose BD in children and adolescents at all, and if there are possible correlates of the diagnoses of pediatric BD. We also asked how often typical manic symptoms (e.g. elated mood) are actually seen in attention deficit hyperactivity disorder (ADHD) patients.

METHODS

Provided by the medical register we had a complete list of all 251 psychiatrists in the area. Using a questionnaire we asked if and how often they diagnose BD among children and adolescents and how often they observe manic-like symptoms in children with ADHD (response rate 61%).

RESULTS

While 63% of all psychiatrists have diagnosed BD in adolescents, only 7.8% did so in children. Age and therapeutic approach of the psychiatrists were associated with the likelihood of having diagnosed BD in children. Furthermore some typical bipolar symptoms were also present in ADHD patients.

CONCLUSIONS

Our study only relied on self-reports of the psychiatrists about the diagnoses and number of cases, but BD in children seems to be rarely diagnosed in outpatient settings in Germany. The design of our study, however, cannot resolve the questions what the reasons are for this low rate of BD diagnoses, e.g. misdiagnoses, overlooking comorbidity or referral strategies. Epidemiological studies are needed and should consider multiple follow-ups.