Screening, assessment and diagnosis in the eating disorders: findings from a rapid review

BACKGROUND

Limited screening practices, minimal eating disorder training in the healthcare professions, and barriers related to help-seeking contribute to persistent low rates of eating disorder detection, significant unmet treatment need, and appreciable associated disease burden. The current review sought to broadly summarise the literature and identify gaps relating to the screening, assessment, and diagnosis of eating disorders within Western healthcare systems.

METHODS

This paper forms part of a Rapid Review series scoping the evidence base for the field of eating disorders, conducted to inform the Australian National Eating Disorders Research and Translation Strategy 2021-2031, funded and released by the Australian Government. ScienceDirect, PubMed and Ovid/Medline were searched for studies published between 2009 and mid 2021 in English. High-level evidence such as meta-analyses, large population studies and Randomised Control Trials were prioritised through purposive sampling. Data from selected studies relating to Screening, Assessment and Diagnosis of eating disorders were synthesised and are disseminated in the current review.

RESULTS

Eighty seven studies were identified, 38% relating to screening and 62% to assessment and diagnosis. The majority of screening studies were conducted in university student samples, showing high prevalence but only modest improvements in help-seeking in those studies that followed up post-screen. In healthcare settings, clinicians continue to have difficulty identifying eating disorder presentations, particularly Binge Eating Disorder, Other Specified Feeding or Eating Disorders, and sub-threshold eating disorders. This is preceded by inadequate and frequently homogenous screening mechanisms and exacerbated by considerable personal and health-system barriers, including self-stigma and lack of resourcing. While all groups are at risk of delayed or no diagnosis, those at particular risk include LGBTQ+ and gender diverse individuals, individuals living in larger bodies, and males.

CONCLUSIONS

A majority of individuals with eating disorders remain undiagnosed and untreated despite a high prevalence of these conditions and increased advocacy in recent years. Research into improving detection and clinician diagnostic skill is extremely limited. Innovative empirical research is strongly recommended to address significant individual and health-system barriers currently preventing appropriate and timely intervention for many. Limited screening in healthcare settings and low rates of eating disorder training in the healthcare professions are just some of the barriers to help-seeking which may contribute to delayed intervention and diagnosis in the eating disorders. This has significant impacts, prolonging treatment when it is finally received, and increasing healthcare costs for both the individual and the healthcare system. The current review is part of a larger Rapid Review series conducted to inform the development of Australia's National Eating Disorders Research and Translation Strategy 2021-2031. A Rapid Review is designed to comprehensively summarise a body of literature in a short timeframe, often to guide policy-making and address urgent health concerns. The Rapid Review synthesises the current evidence-base and identifies gaps in eating disorder research and care, in order to guide decision making and address urgent health concerns. This paper gives a critical overview of the scientific literature relating to the current state of screening, assessment, and diagnosis of eating disorders within Western healthcare systems that may inform health policy and research in an Australian context. It covers screening initiatives in both general and high-risk populations; personal, clinician and healthcare system challenges relating to help-seeking; and obstacles to accurate and timely clinical diagnosis across the eating disorders.

Social and Economic Costs of Attention-Deficit/Hyperactivity Disorder Across the Lifespan

OBJECTIVE

To determine the financial and non-financial costs of Attention-Deficit/Hyperactivity Disorder (ADHD) across the lifespan.

METHOD

The population costs of ADHD in Australia were estimated for the financial year 2018 to 2019 using a prevalence approach to cost estimation across all ages. Financial (healthcare, productivity, education and justice systems, and deadweight losses) and non-financial costs were measured (Disability Adjusted Life Years (DALYs)).

RESULTS

The total social and economic cost of ADHD in 2018 to 2019 were US$12.76 billion (range US$8.40 billion to US$17.44 billion, with per person costs of US$15,664 per year). Productivity costs made up 81% of the total financial costs, followed by deadweight losses (11%), and health system costs (4%). Loss in terms of wellbeing was significant (US$5.31 billion).

CONCLUSION

There is a need to raise public awareness of the considerable socioeconomic impact and burden of ADHD in order to drive investment and policy decisions that improve identification and treatment of ADHD.

Highly efficient and selective aqueous phase hydrogenation of aryl ketones, aldehydes, furfural and levulinic acid and its ethyl ester catalyzed by phosphine oxide-decorated polymer immobilized ionic liquid-stabilized ruthenium nanoparticles

Phosphine oxide-decorated polymer immobilized ionic liquid stabilized RuNPs catalyse the hydrogenation of aryl ketones with remarkable selectivity for the CO bond, complete hydrogenation to the cyclohexylalcohol and hydrogenation of levulinic acid to γ-valerolactone.

Stimulant prescribing for attention deficit hyperactivity disorder (ADHD): what guides clinicians in their choice of an upper limit for dose titration?

OBJECTIVE

There is little evidence to support the current stimulant dose upper limit restrictions in the treatment of attention deficit hyperactivity disorder (ADHD). Within Australasia, there is inconsistency in dose maxima in different jurisdictions. Clinician experience in this area may be worth gauging when trying to improve the understanding of optimal maximal dosing. Our objective was to survey prescribers' experience of whether the current stimulant maximum doses ever conflict with dose optimisation and how such conflicts are managed.

METHOD

We conducted an anonymous online survey of health professionals treating children, adolescents and adults with ADHD.

RESULTS

Responses were received from 128 prescribers, mainly paediatricians (52%) and adult psychiatrists (39%). The designated maximum dose of stimulant was a constraint to dose optimisation experienced by 91% for the Product Information maxima and 82% for their respective state/territory regulations maxima. When clinically indicated, 72% would exceed the designated maxima, either with or without obtaining a second opinion or applying for special authority. Of the remaining 28%, the majority (16%) would opt for polypharmacy, with only two accepting a suboptimal dose.

CONCLUSION

The current stimulant dose maxima act as a constraint to stimulant dose optimisation and may promote undertreatment and polypharmacy.

Erratum to: 36th International Symposium on Intensive Care and Emergency Medicine: Brussels, Belgium. 15-18 March 2016

[This corrects the article DOI: 10.1186/s13054-016-1208-6.].

Short Communication: The Pre-transport management of antemortem stress in cattle: Impact on carcass yield

Grumpelt, B., Hoffer, W., Curie, O., Jones, O., Jones, K., Kimmel, D., McDonald, B., Paterson, R. and Schaefer, A. 2015. Short Communication:The Pre-transport management of antemortem stress in cattle: Impact on carcass yield. Can. J. Anim. Sci. 95: 557–560. Transport and handling of cattle can have a significant impact on carcass weight loss. The purpose of the present study was to examine the effect of providing pre-transport nutritional therapy containing selective amino acids, electrolytes and an energy source, on carcass weight loss. One hundred and ninety British crossbred steers averaging 611 kg were used in the study. The treatment cattle received 1 kg of a nutritional supplement top dressed onto their normal silage diet 24 h prior to transport. Following a 1-h transport period the cattle were processed at a federally inspected beef plant and both hot and cold carcass yield as well as yield grade and quality grade were assessed. Cattle provided with pre-transport nutritional therapy demonstrated a reduction in percentage live weight loss (P<0.01) as well as 1.2% greater hot carcass yield as a proportion of pre-treatment farm weight (P<0.01). The data suggest the use of nutritional support pre-transport is beneficial to carcass yield.

Inter-professional prescribing masterclass for medical students and non-medical prescribing students (nurses and pharmacists): a pilot study

BACKGROUND AND AIMS

Prescribing errors cause significant patient morbidity and mortality. Current legislation allows prescribing by different health professions. Inter-professional collaboration and learning may result in safer prescribing practice. This study aimed to develop, pilot and test the feasibility of a simulated inter-professional prescribing masterclass for non-medical prescribing students, medical students and pharmacists.

METHODS AND RESULTS

A three-scenario, simulated patient session was designed and implemented by an expert panel. Medical students, non-medical prescribing students and pharmacists worked together to formulate and implement evidence-based prescriptions. The Readiness for Inter-professional Learning Score (RIPLS) and a self-efficacy score were administered to the students and the Trust in Physician Score to the simulated patients. Overall, the RIPLS and self-efficacy scores increased. Pharmacists showed the highest rating in the Trust in Physician score. Post masterclass group discussions suggested that the intervention was viewed as a positive educational experience.

CONCLUSION

An inter-professional prescribing masterclass is feasible and acceptable to students. It increases self-efficacy, readiness for inter-professional learning and allows students to learn from, about and with each other. A larger study is warranted and the use of feedback from simulated patients explored further.

Autosomal recessive bestrophinopathy associated with angle-closure glaucoma

PURPOSE

Abnormalities in the BEST1 gene have recently been recognised as causing autosomal recessive bestrophinopathy (ARB). ARB has been noted to have a variable phenotypic presentation, distinct from that of autosomal dominant Best vitelliform macular dystrophy (BVMD). Both conditions are associated with deposits in the retina, a reduced or absent electro-oculography (EOG) light rise, and the risk of developing angle-closure glaucoma. Herein, we describe the clinical and genetic characteristics of a young male diagnosed with ARB associated with angle-closure glaucoma resulting from a novel homozygous mutation in BEST1.

METHODS

All research involved in this case adhered to the tenets of the Declaration of Helsinki. The proband underwent slitlamp examination, retinal autofluorescence imaging and optical coherence tomography after presenting with deteriorating vision. The findings prompted genetic testing with bi-directional DNA sequencing of coding and flanking intronic regions of BEST1. The proband's family members were subsequently screened.

RESULTS

A provisional diagnosis of ARB was made based on the findings of subretinal and schitic lesions on fundoscopy and retinal imaging, together with abnormal EOG and electroretinography. Genetic testing identified a novel homozygous mutation in BEST1, c.636+1 G>A. Family members were found to carry one copy of the mutation and had no clinical or electrophysiological evidence of disease. The proband was additionally diagnosed with angle-closure glaucoma requiring topical therapy, peripheral iridotomies and phacoemulsification.

CONCLUSIONS

Phenotypic overlap, reduced penetrance, variable expressivity and the ongoing discovery of new forms of bestrophinopathies add to the difficulty in distinguishing these retinal diseases. All patients diagnosed with ARB or BVMD should be examined for narrow angles and glaucoma, given their frequent association with these conditions.

Improvement in out-of-hours outcomes following the implementation of Hospital at Night

BACKGROUND

Hospital at Night (H@N) is a Department of Health (England) driven programme being widely implemented across UK. It aims to redefine how medical cover is provided in hospitals during the out-of-hours period.

AIM

To investigate whether the implementation of H@N is associated with significant change in system or clinical outcomes.

DESIGN

An observational study for 14 consecutive nights before, and 14 consecutive nights after the implementation of H@N. Data were collected from the Combined surgical and medical Assessment Unit (CAU), the 18 medical/surgical wards (The Ward Arc) and the four High Dependency Units (The Critical Care corridor) within the Royal Infirmary of Edinburgh.

METHODS

Following an overnight episode of clinical concern, data were gathered on response time, seniority of reviewing staff, patient outcome and the use of Standardized Early Warning Score (SEWS).

RESULTS

Two hundred and nine episodes of clinical concern were recorded before the implementation of H@N and 216 episodes afterwards. There was no significant change in response time in the CAU, Ward Arc or Critical Care corridor. However, significant inter-speciality differences in response time were eradicated, particularly in the Critical Care corridor. Following the implementation of H@N, patients were reviewed more frequently by senior medical staff in CAU (28% vs. 4%, P < 0.05) and the Critical Care corridor (50% vs. 22%, P < 0.001). Finally there was a reduction in adverse outcome (defined as unplanned transfer to critical care/cardiac arrest) in the Ward Arc and CAU from 17% to 6% of patients reviewed overnight (P < 0.01). SEWS was more frequently and accurately recorded in CAU.

CONCLUSION

This is the first study that we are aware of directly comparing out-of-hours performance before and after the implementation of H@N. Significant improvements in both patient and system outcomes were observed, with no adverse effects noted.

Assessment of clinical risk in the out of hours hospital prior to the introduction of Hospital at Night

Overnight medical cover in hospital is less than during daylight hours. We aimed to quantify the numbers of patients deteriorating overnight and their clinical outcome. Data was collected in real time on use of the Standardised Early Warning Score (SEWS), 'time to doctor', seniority of medical review and clinical outcome. 136 incidents of clinical concern were noted on the general wards with a median response time of 5 minutes for SEWS>4 and 10 minutes if SEWS<4. 159 incidents were recorded in critical care. There was significant inter-speciality variation in median response times and seniority of responding staff, particularly within critical care, which recorded the slowest times across the hospital. This will be reassessed following the establishment of Hospital at Night.

SURGICAL REPAIR FOLLOWED BY FUNCTIONAL REHABILITATION FOR ACUTE AND CHRONIC ACHILLES TENDON INJURIES: EXCELLENT FUNCTIONAL RESULTS, PATIENT SATISFACTION AND NO RERUPTURES

BACKGROUND

We evaluated 46 patients who underwent surgical repair of the Achilles tendon at our institution during a 4.5-year period, followed by early weight bearing, aiming to assess their return to activities, rerupture rate and satisfaction.

METHODS

A cohort of 46 patients who underwent Achilles tendon repair at our institution during a 4.5-year period, with a modified triple mini-Becker suture technique, for both acute as well as chronic Achilles tendon ruptures were studied. These patients were reviewed at a minimum of 2.5 years follow up (average 4.5 years ranging from 2.5 to 6.5 years), by chart review and questionnaire, to determine the functional outcome as well as patient satisfaction following an active postoperative protocol involving full weight-bearing ambulation in a controlled ankle motion walker and active stretching, followed by a graduated strengthening programme.

RESULTS

We found a very high level of satisfaction, with few minor complications and no reruptures in either the early or the delayed repair groups.

CONCLUSION

We believe that surgical repair using this technique associated with an early return to protected full weight-bearing ambulation and an active early rehabilitation programme provides not only excellent functional results, patient satisfaction and a zero rerupture rate, but also much less morbidity in the first 3 months and a quicker overall recovery compared with non-operative treatment.

Assessment of radionuclide arthrography in the evaluation of loosening of knee prostheses

BACKGROUND

Radionuclide arthrography (RNA) is an established technique in the evaluation of hip prostheses but there is scant literature on its role in knee prostheses and no data specifically related to unicompartmental knee prostheses. We reviewed our experience with radionuclide arthrography in total (TKRs) and unicompartmental (UKRs) knee arthroplasties.

METHODS

A retrospective review of 66 consecutive RNA studies that either had direct surgical correlation or arthroscopic assessment in conjunction with at least 12 months of clinical and radiological follow-up. These formed the basis of our case note review. 26 studies had a confirmed diagnosis of prosthetic loosening.

RESULTS

By using standardised criteria for diagnosis and an early and late imaging protocol at 30 min and 4 h, RNA had an overall sensitivity of 88% and a specificity of 88% for the diagnosis of prosthetic loosening. The individual sensitivities and specificities were 93% and 86% for TKRs and 82% and 92% for UKRs. The technique was unable to detect femoral component loosening unless a long femoral stem was present, although only 8% of episodes of prosthetic loosening did not involve the tibial component.

CONCLUSION

Radionuclide arthrography should be considered as a useful diagnostic test for the evaluation of loosening of the tibial component of knee prostheses but requires early and late imaging and close attention to detail to achieve optimal results.

Prediction of in-hospital mortality and length of stay using an early warning scoring system: clinical audit

This aim of this study was to assess the impact of the introduction of a standardised early warning scoring system (SEWS) on physiological observations and patient outcomes in unselected acute admissions at point of entry to care. A sequential clinical audit was performed on 848 patients admitted to a combined medical and surgical assessment unit during two separate 11-day periods. Physiological parameters (respiratory rate, oxygen saturation, temperature, blood pressure, heart rate, and conscious level), in-hospital mortality, length of stay, transfer to critical care and staff satisfaction were documented. Documentation of these physiological parameters improved (P<0.001-0.005) with the exception of oxygen saturation (P=0.069). The admission early warning score correlated both with in-hospital mortality (P<0.001) and length of stay (P=0.001). Following the introduction of the scoring system, inpatient mortality decreased (P=0.046). Staff responding to a questionnaire indicated that the scoring system increased awareness of illness severity (80%) and prompted earlier interventions (60%). A standardised early warning scoring system improves documentation of physiological parameters, correlates with in-hospital mortality, and helps predict length of stay.

Naming, blaming and shaming?

Few doctors at the centre of complaints or disciplinary proceedings wish to be publicly named. Publication of a doctor's name can adversely affect his or her reputation, patients, and family members, even if the allegation is ultimately not upheld. Yet, there is a strong public interest in freedom of speech and transparency of complaints and disciplinary processes. In determining whether to grant name suppression, complaints agencies and disciplinary tribunals are required to balance competing public and private interests. In New Zealand, the Health and Disability Commissioner has responsibility for investigating complaints about the quality of medical care. The Commissioner's current practice is not to publicly name doctors under investigation, or even those who are found to have breached a patient's rights. This approach fits well the non-punitive, rehabilitative focus of New Zealand's medical regulatory system. In the rare cases where a matter reaches the threshold for disciplinary action, the balance tips in favour of disclosure.

A new technique for reconstructing the medial patellofemoral ligament

Many surgical techniques exist for treating patella instability. Over recent years, attention has focussed on reconstruction of the medial patellofemoral ligament (MPFL). We report a procedure involving a lateral release, distal realignment of the tibial tubercle and anatomic reconstruction of the MPFL using a graft composed of a redundant strip of medial retinacular tissue. Nineteen patients (twenty-one knees) with chronic patellofemoral instability who had failed conservative treatment underwent this procedure and were assessed clinically and radiologically at an average of 23 months post-operation. No patients were lost to follow-up. There was no recurrence of subluxation or dislocation. All achieved levels of activity comparable to or improved compared to pre-operative uninjured levels. This combined procedure incorporating a previously un-described method of reconstructing the MPFL gives superior results compared to previous studies. No graft donor site morbidity occurred and patient outcome scores, especially objective stability of the patella to lateral shift, were excellent.

Protecting patients' rights in New Zealand

For 30 years, medical malpractice litigation has effectively been barred in New Zealand by accident compensation laws. Victims of medical error are rehabilitated and compensated through a no-fault, state-funded compensation scheme. Patients' rights (and providers' duties) are set out in a Code of Consumers' Rights, which applies to all providers of health and disability services, ranging from surgeons to traditional Maori healers and unpaid caregivers. Organisational providers such as hospitals are also covered. Complaints alleging a breach of the Code are resolved at the lowest appropriate level by a statutory Ombudsman, the Health and Disability Commissioner. Resolution techniques include advocacy, mediation and investigation, which may result in a finding of breach of the Code. The emphasis is on "resolution, not retribution" and "learning, not lynching". The Commissioner makes remedial recommendations, but does not award damages. Competence concerns are referred to professional registration boards, and serious breaches are referred for disciplinary proceedings. The New Zealand model of legislating patients' rights and enforcing them via an independent Commissioner is an interesting variant of professional self-regulation, and seeks to promote resolution of individual complaints and systemic improvements in health care quality. Investigation reports are widely distributed to promote learning. Despite initial professional resistance, the Office is becoming recognised for its key role in a regulatory system where medical malpractice claims are barred. A case study involving misdiagnosis of a fatal heart attack illustrates the flexibility of the New Zealand response to medical errors.

Reflective testing: how useful is the practice of adding on tests by laboratory clinicians?

AIMS

To investigate the clinical value and practice of reflective testing, a new term to describe the practice of adding on tests when reporting or clinically authorising results.

METHODS

A consultant medical biochemist collected over a calendar year (2001) copies of clinical biochemistry reports on samples to which he had added on either iron studies (iron, total iron binding capacity (TIBC), and percentage saturation), or vitamin D. Iron studies and vitamin D were added on when biochemical results, available clinical information, demographic data, and clinical experience-or combinations thereof-suggested the possibility of haemochromatosis or vitamin D deficiency, respectively. The number of reports that the consultant authorised was estimated for the same calendar year. The number and percentage of raised TIBC percentage saturation and low vitamin D results from the tests that were added on were collated.

RESULTS

Raised TIBC saturation values were found in 28 patients (18.7% of the iron studies added on), of whom 16 were subsequently genotyped, eight having a genotype consistent with haemochromatosis. Thirty one patients with vitamin D deficiency (23.1% of the vitamin D tests added on) were identified.

CONCLUSIONS

The addition of iron studies and vitamin D tests by a laboratory clinician, when reporting, resulted in the identification of patients with haemochromatosis and vitamin D deficiency. The practice of adding on tests should be called reflective testing, because it is discretionary and is based on the clinical judgement of a laboratory clinician in the interpretation of results.

Patients' rights in New Zealand: complaints resolution and quality improvement

"Patients' rights" has become a familiar catchword in western countries in recent years. In New Zealand the Office of the Health and Disability Commissioner was established in 1994 to promote and protect patients' rights. The Commissioner also facilitates the resolution of complaints relating to the infringement of patients' rights as set out in the Code of Health and Disability Services Consumers' Rights. Victims of medical misadventure in New Zealand are compensated through a no-fault, state-funded rehabilitation and compensation scheme. The regulatory environment is rehabilitative rather than punitive. This framework is consistent with a systems approach to reducing errors and improving patient safety, and the Commissioner seeks to use the resolution of individual complaints as a tool for improving the quality of care throughout the health care system.

Cognitive versus behavior therapy in the group treatment of obsessive-compulsive disorder

This study examined the effects of cognitive-behavior therapy (CBT) compared with traditional behavior therapy (exposure and response prevention [ERP]) in the group treatment of obsessive-compulsive disorder. Of the 76 participants who started treatment, 38 were wait-listed for 3 months before treatment to assess possible course effects. Both treatments were superior to the control condition in symptom reduction, with ERP being marginally more effective than CBT by end of treatment and again at 3-month follow-up. In terms of clinically significant improvement, treatment groups were equivalent on the conclusion of treatment, but 3 months later significantly more ERP participants met criteria for recovered status. Only 1 of 7 belief measures changed with treatment improvement, and the extent of this cognitive change was similar between CBT and ERP groups. Discussion includes consideration of optimal formats for the delivery of different types of treatment.

Reconstruction of the lateral ligaments of the ankle using semi-tendinosis graft

Injury to the lateral ligaments of the ankle is one of the most common sports-related injuries. Although these injures generally resolve with non-operative treatment reconstruction of the lateral ligaments of the ankle is occasionally necessary. We report the surgical technique and result of reconstruction of the anterior talo-fibular ligament using a semi-tendinosis free graft in 26 patients with an average follow-up of 24 months. 81% of patients reported complete resolution or substantial improvement in instability, swelling and sharp pain. Episodes of functional instability persisted in five patients post operatively. No significant differences were noted between the operated and contra-lateral non-operated ankle in range of motion or uniaxial balance assessment. Kin-Com testing of hamstring strength showed no differences between sides. Short term results suggest that this ligament reconstruction provides good results without sacrifice of peroneal function and has minimal donor site morbidity.

A randomised, double-blind, placebo-controlled trial of dexamphetamine in adults with attention deficit hyperactivity disorder

OBJECTIVE

The aim of this paper is to determine the efficacy of dexamphetamine in adult attention deficit hyperactivity disorder (ADHD) in a naturalistic setting.

METHOD

A randomised, double-blind, placebo-controlled study of dexamphetamine was conducted by two psychiatrists in private practice who saw a total of 68 consecutive referrals of patients thought to have ADHD by their referring general practitioners. Patients were admitted to the study if their current level of ADHD symptoms satisfied DSM-IV criteria (modified for use in adults), and were not currently comorbid for major mood disturbance or substance abuse. Response to medication was assessed by repeated administration of these modified DSM-IV criteria, self- and relatives' rating, as well as clinician rating using the Clinical Global Impressions Scale. More general outcome measures included the Brief Symptom Inventory and a patient satisfaction questionnaire. Medication side effects were recorded, including monitoring blood pressure and weight change. Urinalysis monitored concurrent substance usage and compliance.

RESULTS

Dexamphetamine had a significant therapeutic response exceeding the placebo response (p = 0.045). The response was similar in both genders and across the age range. It was detected by patients, their relatives and the two clinicians. The only significant side effect was weight loss. One patient on dexamphetamine discontinued the trial because of an event possibly related to the medication.

CONCLUSIONS

In the short term, dexamphetamine appears to be efficacious in treating adult ADHD. As this is the first study in the literature, the result requires replication. Given that stimulant medication use in adult ADHD appears to be long-term, studies of long-term efficacy need to be carried out.

Paediatric assessment in a residential child and adolescent psychiatry unit

OBJECTIVE

To document the health status, comorbidity and functional impairments experienced by a group of psychiatrically disturbed children and adolescents.

METHODOLOGY

A detailed study of consecutive admissions to a residential unit over a two-year period was undertaken. All admissions had a comprehensive paediatric, speech pathology and psychiatric assessment.

RESULTS

Compared to the general population, there was a significant history of developmental delay and low birthweight, but only a slightly greater prevalence of antenatal problems. Clumsiness (37%), severe speech and language disorder (32%), and hearing loss (15%) were prominent. Only 25% had no history of comorbid medical or neurological disorders.

CONCLUSION

Children and adolescents presenting with moderate to severe mental health morbidity may have pre-existing comorbid medical problems, as well as unrecognised difficulties and impairments in other skills areas. Multidisciplinary assessment and intervention should be an integral part of the residential programme.