Diagnostic trajectories in child and adolescent mental health services: exploring the prevalence and patterns of diagnostic adjustments in an electronic mental health case register

Helpful or harmful? The effect of a diagnostic label and its later retraction on person impressions

Diagnostic labels for mental health conditions can inadvertently reinforce harmful stereotypes and exacerbate stigma. If a diagnosis is incorrect and a label is wrongly applied, this may negatively impact person impressions even if the inaccurate label is later corrected. This registered report examined this issue. Participants (N = 560) read a vignette about a hospital patient who was either diagnosed with schizophrenia, diagnosed with major depressive disorder, or not diagnosed with a mental health condition. The diagnostic labels were later retracted strongly, retracted weakly, or not retracted. Participants completed several stigma measures (desire for social distance, perceived dangerousness, and unpredictability), plus several inferential-reasoning measures that tested their reliance on the diagnostic label. As predicted, each mental health diagnosis elicited stigma, and influenced inferential reasoning. This effect was stronger for the schizophrenia diagnosis compared to the major depressive disorder diagnosis. Importantly, the diagnostic label continued to influence person judgments after a clear retraction (strong or weak), highlighting the limitations of corrections in reducing reliance on person-related misinformation and mental health stigma.

Antipsychotic prescribing: national findings of children and adolescents attending mental health services in Ireland

Antipsychotic prescribing trends vary internationally, albeit off-label use remains high (i.e., target symptoms). We aim to describe antipsychotic use, target conditions, target symptoms and dosing regimens in children and adolescents in Ireland. We used a sampled cohort from a national audit of children and adolescents attending mental health services with predefined inclusion and exclusion criteria from Jul-2021 to Dec-2021 who were prescribed at least one psychotropic medication and up to and including 17-years of age (n = 3528). Each service provided anonymised data. We described the frequency of antipsychotic medication, medication type, target condition, target symptom and medication doses. We used multivariable logistic regression, adjusted with available co-variates to assess the association of being prescribed an antipsychotic medication. Twelve percentage (n = 437) were prescribed an antipsychotic and 16-17-years (n = 211, 48.3%) was the most common age category. The commonest reason for prescribing an antipsychotic was target symptoms (i.e., off-label use) (n = 329; 75.%) and of these symptoms, agitation (n = 77/329; 25%) and irritability (56/239; 25%) were the most common. Quetiapine (n = 127; 29%) was the most common antipsychotic, followed by risperidone (n = 125; 28.6%), aripiprazole (n = 107; 24.5%), and olanzapine (n = 66; 15.1%). In adjusted analysis, having a psychotic disorder ((adjusted-odds-ratio) aOR: 39.63, CI 95%, 13.40-117.22), bipolar disorder (aOR: 16.96, CI 95%, 3.60-80.00), autism spectrum disorder (aOR: 3.24, CI 95%, 2.45-4.28) or aggression symptoms (aOR: 16.75, CI 95%, 7.22-38.89) was associated with prescribing an antipsychotic medication. This is the first study in children and adolescents that describes the target conditions and target symptoms for antipsychotic use in Ireland. Our results show a high proportion of antipsychotic prescribing based on target symptoms rather than target condition or diagnosis.

Evidence for distinct genetic and environmental influences on fear acquisition and extinction

BACKGROUND

Anxiety disorders are highly prevalent with an early age of onset. Understanding the aetiology of disorder emergence and recovery is important for establishing preventative measures and optimising treatment. Experimental approaches can serve as a useful model for disorder and recovery relevant processes. One such model is fear conditioning. We conducted a remote fear conditioning paradigm in monozygotic and dizygotic twins to determine the degree and extent of overlap between genetic and environmental influences on fear acquisition and extinction.

METHODS

In total, 1937 twins aged 22-25 years, including 538 complete pairs from the Twins Early Development Study took part in a fear conditioning experiment delivered remotely via the Fear Learning and Anxiety Response (FLARe) smartphone app. In the fear acquisition phase, participants were exposed to two neutral shape stimuli, one of which was repeatedly paired with a loud aversive noise, while the other was never paired with anything aversive. In the extinction phase, the shapes were repeatedly presented again, this time without the aversive noise. Outcomes were participant ratings of how much they expected the aversive noise to occur when they saw either shape, throughout each phase.

RESULTS

Twin analyses indicated a significant contribution of genetic effects to the initial acquisition and consolidation of fear, and the extinction of fear (15, 30 and 15%, respectively) with the remainder of variance due to the non-shared environment. Multivariate analyses revealed that the development of fear and fear extinction show moderate genetic overlap (genetic correlations 0.4-0.5).

CONCLUSIONS

Fear acquisition and extinction are heritable, and share some, but not all of the same genetic influences.

BOAM: A Visual, Explanatory Diagnostic and Psychoeducation System Used in Collaboration with Families-Feasibility and Acceptability for Children Who Are Non-Responsive to Treatment as Usual

Many children referred to mental health services have neurodevelopmental problems, which are not always recognized because the resulting emotional and behavioral problems dominate diagnosis and treatment. BOAM (Basic needs, Order, Autonomy and Meaning) is a new diagnostic system consisting of imaginative models that explain the complexity of symptoms and underlying neuropsychological problems in a simple way. It is designed to be used in a transparent, collaborative process with families, so that family members can better understand the nature of mental health problems, thus increasing self-knowledge and mutual understanding. In this study, the feasibility of the BOAM diagnostic trajectory and subsequent treatment informed by this trajectory are evaluated clinically in 34 children who have not responded to or relapsed after treatment as usual (TAU). Parents completed questionnaires pre-test, post-test and at a 3-month follow-up. The treatment drop-out rate was 2.9%. Post-test, parents rated the BOAM trajectory positively. The questionnaires (measuring child psychopathology, attention, executive functioning, family functioning, partner relationships and parenting stress) demonstrated sensitivity to change, and therefore, seems appropriate for a future effectiveness study. A limitation was the high percentage of missing measurements both post-test (41%) and at the follow-up (41%). The BOAM diagnostic trajectory and subsequent treatment may be a feasible alternative for children who do not respond to or relapse after TAU.

Autism spectrum disorders as a risk factor for adolescent self-harm: a retrospective cohort study of 113,286 young people in the UK

BACKGROUND

Individuals with autism spectrum disorder (ASD) are at particularly high risk of suicide and suicide attempts. Presentation to a hospital with self-harm is one of the strongest risk factors for later suicide. We describe the use of a novel data linkage between routinely collected education data and child and adolescent mental health data to examine whether adolescents with ASD are at higher risk than the general population of presenting to emergency care with self-harm.

METHODS

A retrospective cohort study was conducted on the population aged 11-17 resident in four South London boroughs between January 2009 and March 2013, attending state secondary schools, identified in the National Pupil Database (NPD). Exposure data on ASD status were derived from the NPD. We used Cox regression to model time to first self-harm presentation to the Emergency Department (ED).

RESULTS

One thousand twenty adolescents presented to the ED with self-harm, and 763 matched to the NPD. The sample for analysis included 113,286 adolescents (2.2% with ASD). For boys only, there was an increased risk of self-harm associated with ASD (adjusted hazard ratio 2·79, 95% CI 1·40-5·57, P<0·01). Several other factors including school absence, exclusion from school and having been in foster care were also associated with a higher risk of self-harm.

CONCLUSIONS

This study provides evidence that ASD in boys, and other educational, social and clinical factors, are risk factors for emergency presentation with self-harm in adolescents. These findings are an important step in developing early recognition and prevention programmes.

How Does It Feel to Have One's Psychiatric Diagnosis Altered? Exploring Lived Experiences of Diagnostic Shifts in Adult Mental Healthcare

BACKGROUND

Though the socio-emotional significance of psychiatric diagnoses and the frequency of transitions between diagnostic classifications are widely acknowledged, minimal research reveals how "diagnostic shifts" are subjectively experienced by psychiatric service-users.

AIM

This study investigated how adult service-users make sense of diagnostic shifts and their impacts on one's life.

METHODS

Twenty-seven people with self-reported experiences of diagnostic shifts opted into this qualitative study. Virtual narrative interviews invited participants to share their "diagnosis stories." Interview transcripts were analyzed using narrative thematic analysis to identify common and divergent experiences across participants.

RESULTS

Diverse experiences of diagnostic shifts were related: diagnostic shifts could both promote and undermine clinical trust, therapeutic engagement and self-understanding. The analysis suggested that shared and divergent experiences could be attributed to two dimensions of narratives: participants' Interpretations of Diagnostic Shifts and Diagnosis-Specific Factors. Regarding the former, analysis produced a typology of three possible interpretations of diagnostic shifts, which were linked with consistently different antecedents, experiences and consequences. The latter dimension captured how experiences of diagnostic shifts also hinged on the unique meanings ascribed to the specific diagnoses gained and lost, particularly in relation to their perceived severity, stigma, personal associations, and related communities.

CONCLUSIONS

Findings revealed how diagnostic shifts can be experienced as both traumatic and life-enhancing, depending on their social and subjective context. Understanding the range and predictors of variable experiences of diagnostic shifts is vital for sensitive clinical practice and communication.

How does diagnostic labelling affect social responses to people with mental illness? A systematic review of experimental studies using vignette-based designs

BACKGROUND

An outstanding question in the stigma literature is the extent to which negative responses are provoked by diagnostic labels, rather than observable symptoms of mental illness. Experimental studies frequently use vignettes to identify the unique effects of diagnostic labels on social responses to people with mental illness, independent of their behaviour or socio-demographic characteristics.

AIMS

The current article identifies, evaluates, and synthesises the body of experimental vignette studies of labelling effects.

METHODS

A systematic review was conducted in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Eligible studies were subjected to quality evaluation and narrative synthesis.

RESULTS

Of 1511 articles screened, 22 met inclusion criteria. Most studies focused on the diagnostic categories of attention deficit hyperactivity disorder, schizophrenia spectrum disorders, and autism spectrum disorder. The literature reported diverse effects, with diagnostic disclosure either exacerbating, mitigating, or not affecting stigma. The quality of studies was generally acceptable but the review identified an over-reliance on convenience sampling and unvalidated measures.

CONCLUSIONS

Results highlight the complexity of labelling effects, which diverge across diagnostic categories and social contexts. The review emphasises the need for expansion of diagnostic labels and contexts studied, standardisation of validated attitude scales, incorporation of behavioural outcomes, and diversification of samples.

Lived Experiences of Diagnostic Shifts in Child and Adolescent Mental Health Contexts: a Qualitative Interview Study with Young People and Parents

Psychiatric diagnoses are important resources in helping young people and families make sense of emotional or behavioural difficulties. However, the poor reliability of diagnoses in childhood means many young service-users experience their diagnosis being removed, revised or supplemented over time. No previous research has investigated how young service-users experience, understand or respond to alteration of their original diagnosis. The current study adopted a qualitative approach to explore the lived experience of diagnostic shifts in youth mental health contexts. Narrative interviews were conducted with families living in Ireland, who had direct experience of diagnostic shifts. Participants included 21 parents (19 female) and 14 young people (8 female, mean age = 14). Thematic analysis explored the range of interpretations and implications of diagnostic shifts in families' lives, identifying three themes that underpinned participants' narratives. Diverse Trajectories & Experiences outlined the variety of contexts for diagnostic shifts, ways they were communicated to parents and young people, and their clinical consequences. A Process of Readjustment captured processes of emotional and conceptual adaptation that followed a diagnostic shift. Finally, Social Repositioning explored how diagnostic shifts could prompt changes to interpersonal relations, social identity and stigma experiences. The study shows that diagnostic shifts carry significant emotional, social and practical repercussions. While diagnostic shifts may threaten the therapeutic relationship and service-user understanding, they also offer opportunities to enhance young people's self-concept, social relationships and therapeutic engagement. Clinician awareness of the socio-emotional implications of diagnostic shifts is vital to inform sensitive communication and support strategies.