Screening in High Schools to Identify, Evaluate, and Lower Depression Among Adolescents: A Randomized Clinical Trial

IMPORTANCE

Adolescent major depressive disorder (MDD) prevalence has nearly doubled in the past decade. The US Preventive Services Task Force endorses universal adolescent MDD screening in primary care; however, most adolescents lack preventive health care, resulting in worsening disparities in MDD screening and treatment.

OBJECTIVE

To evaluate the effectiveness of universal adolescent MDD screening in the school setting in an effort to reduce disparities and improve MDD identification and treatment initiation.

DESIGN, SETTING, AND PARTICIPANTS

This randomized clinical trial, conducted from November 6, 2018, to November 20, 2020, compared the usual school practice of targeted or selected screening based on observable behaviors of concern with universal MDD screening. Students within an identified school were randomized by grade to 1 of the 2 study groups. Study groups were compared using mixed-effects logistic regression. Participants included students in grades 9 through 12 enrolled at 1 of the 14 participating Pennsylvania public high schools.

INTERVENTIONS

In targeted screening, students with behaviors prompting concern for MDD were referred to the Student Assistance Program (SAP), mandated in all Pennsylvania schools. The SAP determined follow-up recommendations. In universal screening, all students completed the Patient Health Questionnaire-9 (PHQ-9); students with positive scores proceeded to SAP. The universal screening group could also have targeted referral to SAP for concerning behavior independent of the PHQ-9.

MAIN OUTCOMES AND MEASURES

The primary outcome was initiation of MDD treatment or services based on data collected by school SAP teams during the academic year.

RESULTS

A total of 12 909 students were included (median age, 16 years [range, 13-21 years]; 6963 male [53.9%]), of whom 2687 (20.8%) were Hispanic, 2891 (22.4%) were non-Hispanic Black, 5842 (45.3%) were non-Hispanic White, and 1489 (11.5%) were multiracial or of other race or ethnicity. A total of 6473 students (50.1%) were randomized to universal screening, and 6436 (49.9%) were randomized to targeted screening. Adolescents in the universal screening group had 5.92 times higher odds (95% CI, 5.07-6.93) of being identified with MDD symptoms, 3.30 times higher odds (95% CI, 2.49-4.38) of SAP confirming follow-up needs, and 2.07 times higher odds (95% CI, 1.39-3.10) of initiating MDD treatment. No differences were identified in initiation for planned subgroup analyses by sex or race and ethnicity.

CONCLUSIONS AND RELEVANCE

In this randomized clinical trial, universal school-based MDD screening successfully increased identification of MDD symptoms and treatment initiation among adolescents, confirming the value of this approach to address this rising public health concern.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT03716869.

Child and adolescent Liaison-Consultation Psychiatry and Psychosomatic Medicine in a Clinical-Teaching Hospital

Psychosomatic medicine explores the psychological, behavioral, and social elements that influence people's health and quality of life. This discipline develops skills and knowledge used in the evalua tion and management of psychosocial elements interfering in the process of illness and healing. The Child and Adolescent Consultation-Liaison Psychiatry (CACLP) is a discipline that has been empi rically installed in order to favor adherence to treatments and recovery of children and teenagers du ring the process of illness. There is a need for developing this discipline in Chile, but so far there are limited national and international records and literature dedicated to it. The objective of this article is to update the concepts of structure and describe how a CACLP unit in a high complexity teaching hospital works in general, discussing the clinical challenges involved in these issues.

Should a Psychiatrist Prescribe a Nanodrug to Help Parents Monitor a Teen's Adherence?

This case explores ethical questions about tracking medication adherence in a 16-year-old patient with schizophrenia. Relevant stakeholders are the teen, the parents, and society. How those stakeholders' interests should be considered is explored here in the context of the psychiatrist's professional care management responsibilities and the burdens each stakeholder must bear over the course of the patient's care.

[Towards personalized child and adolescent psychiatry care by using routinely registered data from everyday clinical practice]

Studying differences in the course and treatment effects of psychiatric disorders between subgroups of patients can provide suggestions to improve everyday clinical practice.<br/> AIM: To illustrate how routinely registered data from child and adolescent psychiatry can be used to gain insight into differences in the development of patient groups.<br/> METHOD: Multilevel analyses in four subgroups of youths with an autism spectrum disorder (asd; n = 1681; boys/girls, with/without comorbid psychiatric disorder) to investigate differences in the development of quality of life during the first six months of treatment.<br/> RESULTS: Subgroups of youths with asd showed differences in development of quality of life, which can provide suggestions to establish personalized care.<br/> CONCLUSION: Multicenter research in large samples is needed to investigate the robustness of our findings. The 'Research Data Infrastructure', containing routine outcome monitoring and electronic medical record data from more than 117.000 youths in child and adolescent psychiatry, offers a unique opportunity to perform large scale practice based research.

On aggressiveness and violence in adolescence

When considering aggressiveness and violence during adolescence, we must take into account multiple senses, which range from the healthy assertion of one's own space before others to the repetition of traumatic violent experiences such as the violation of bodily and spatial-temporal boundaries. The author presents a survey of the views of different authors within psychoanalytical literature which allows us to question these terms, and turn then to the exploration of clinical practice. In studying the latter, acting out is brought to the fore, noting that not every adolescent act connotes a risk. The acts tackled in this case are those that, owing to their characteristics, may often endanger the very life of the adolescent. The author presents clinical material that focuses on adolescent acting out, highlighting the question of how to create, through the transference-countertransference axis, a space within the analytic session where the patient's capacity to think may be incorporated, thus allowing the anticipation of action.

The Emergency Department: Challenges and Opportunities for Suicide Prevention

Emergency departments (EDs) can offer life-saving suicide prevention care. This article focuses on the ED and emergency services as service delivery sites for suicide prevention. Characteristics of EDs, models of emergency care, ED screening and brief intervention models, and practice guidelines and parameters are reviewed. A care process model for youths at risk for suicide and self-harm is presented, with guidance for clinicians based on the scientific evidence. Strengthening emergency infrastructure and integrating effective suicide prevention strategies derived from scientific research are critical for advancing suicide prevention objectives.

[The Severe Chronic Irritability Concept: A clinical dimension to consider in child and adolescent]

INTRODUCTION

For a decade, the concept of irritability has known a renewed interest in infant and child psychopathology. Indeed, longitudinal follow-up studies clearly highlighted their predictive value - in the short, medium and long terms - of a broad field of behavioral disorders and emotion dysregulation. This dimensional and transnosographic approach of irritability, coupled with the latest neuroscience data, points out that irritability could be the equivalent of a psychopathological marker, covering both a neurobiological, cognitive and emotional component. It is a major challenge today to better understand the developmental sequence of severe chronic irritability and its predictive influence on the etiology of mental disorders from childhood to adulthood.

METHOD

We briefly review here the latest current data on this topic.

RESULTS

The important point is that chronic and non-episodic irritability in children, associated with strong emotional sensitivity to negative events and frequent access of anger, could have a predictive value for progression to anxiety disorder or severe mood disorder but not to bipolar disorder as it was believed until now. The risk of developing a bipolar disorder would be more frequently correlated with the notion of transient and episodic irritability in a context of previous family history of bipolar disorder.

CONCLUSION

Further studies are expected to narrow the discriminative validity of this notion of severe irritability and confirm or not its relevance as a major clinical criterion of Severe Mood Disorders in children and adolescents introduced in the last version of DSM (DSM-5).

[Interpersonal therapy (IPT) in child psychiatry and adolescent]

INTRODUCTION

Depression disorder may become the first cause of morbidity by 2030, according to the World Health Organization. It is actually one of the main causes of disease and handicap in children aged from 10 to 19. The major risk is suicide, whose prevalence is estimated, in France, around 6.7 for 100,000, which is probably underestimated. At present, the discussions about prescription of antidepressants in an adolescent's depression remain intense which is why psychotherapy becomes the first choice of treatment. We propose here to present one of them, Interpersonal PsychoTherapy (IPT), which remains largely unknown in France, and its adaptations in the adolescent population.

PRESENTATION OF IPT

IPT is a brief psychotherapy, structured in twelve to sixteen sessions, which was created by Klerman and Weissman in the seventies inspired by the biopsychosocial model of Meyer, interpersonal theory of Sullivan, and attachment theory of Bowlby. It is divided into three parts: the initial phase, the intermediate phase, and the termination phase.

ADAPTATION FOR ADOLESCENTS

IPT was adapted for adolescents by Mufson in 1993, but a few modifications must be considered. Parental implication is the first. Indeed, parents, rather than the adolescent, often ask for the consultation; but it is the latter who benefits from the therapy. Parents may be met at some point in the therapy, for example between each phase and at the end. The initial phase is very close for the adolescent as for the adult; but the therapist must be careful about employing the "sick role" which can be used by the adolescent to avoid school, and as a consequence, to exacerbate the interpersonal deficit. The intermediate phase focuses on one of the four interpersonal issues: complicated bereavement, role transition, interpersonal role disputes, and interpersonal deficit. Complicated bereavement may become problematic when prolonged or when the adolescent had complicated relations with the deceased. The therapist essentially works on emotion verbalization. The role of transition is very common during adolescence: children become adults, they pass from high school to college, or their parents get divorced, etc. The patient and the therapist work on giving up the old role with its emotional expression (guilt, anger, and loss), and acquiring new skills, and identifying positive aspects of the new role. Interpersonal role disputes are common during adolescence, with parents or teachers for example. To determine a treatment plan, the therapist may first determine the stage of the role dispute, among impasse, renegotiation, or dissolution, and then work on the communication mode of the patient. At the least, the interpersonal deficit may be the most difficult area to work on because of the risk of psychiatric comorbidity. The therapist must be especially careful about anxious disorder which may complicate the psychotherapy and for which IPT is not the best therapy. The termination phase focuses on the new skills and abilities and works on the future without therapy. IPT is one of the psychotherapies recommended in the treatment of depression disorder in the international recommendations. But in France, all psychotherapies are considered equally. This may be a consensual approach, but the authors wonder if it is the best, especially to motivate research in the psychotherapy field.

OTHER INDICATIONS

Finally, IPT has been developed in other indications in the past years, and many others are presently in research projects: depression during pregnancy, prevention of depression relapse, eating disorders, attention deficit and hyperactivity disorder, self-harm for example.

CONCLUSION

Its validity, simplicity and efficacy should stimulate psychiatrists and residents to train themselves to IPT.

[How do adolescent inpatients experience seclusion and other coercive measures?]

BACKGROUND

The reduction of coercive measures in psychiatry, particularly of seclusion, is considered to be a matter of some urgency. When policy changes with regard to coercive measures are being considered, the wishes and preferences of patients should be taken into account. Up till now, however, there have not been any studies that have examined how adolescent inpatients feel about coercive measures.

AIM

To examine the way adolescent inpatients feel about seclusion and other forms of coercive measures.

METHOD

Adolescent inpatients in a Dutch centre for orthopsychiatry (n = 34) were asked about their experiences with and their thoughts on coercive measures in general and on seclusion in particular.

RESULTS

Thirty-two respondents took part. More than half of the 18 adolescents who had had prior experiences of coercive measures preferred seclusion to involuntary medication.

CONCLUSION

Policy-makers who want to reduce coercive measures in psychiatry should not focus primarily on the reduction of seclusion. Patient preferences, which vary depending on the nature of the patient population, need to be considered carefully and taken into account.

[Youth F-ACT: mapping the problems of a special population]

BACKGROUND

Youth f-act teams have been set up for the purpose of providing the care needed by young people suspected of having complex psychiatric problems.

AIM

To obtain insight into the problems of this population at the beginning and at the end of treatment provided by the youth f-act team in South Limburg.

METHOD

We based our study on a cohort of 68 patients who met the criteria for f-act during the period from January 2013 up to and including October 2014. We evaluated the effect of f-act treatment of 41 patients who had completed their treatment during the above-mentioned period. We examined the records for patients' daily functioning and quality of life and we noted patient characteristics at beginning and end of treatment in order to collect more information about the problems of this population.

RESULTS

Besides having psychiatric problems, our study population also appeared to have malfunctioned at several other areas. At the end of treatment patients' daily functioning was found to have improved, but there was little or no improvement in patients' quality of life.

CONCLUSION

Treatment by the youth f-act team seems able to deal successfully with the problems of the young people under study. However, factors that influence patients' quality of life need to be studied more thoroughly so that in the future the quality of treatment will be of a higher standard.

The DSM-5: an opportunity to affirm "the whole child" concept in child and adolescent psychiatric residency training

This article summarizes a 2013 American Psychiatric Association annual meeting presentation on the incorporation of the DSM-5 into child and adolescent psychiatric residency training with focus on the potential benefits of the DSM-5 for medical education.

Mood disorders in adolescents: concepts and interrogations among Francophone psychiatrists

BACKGROUND

With the publication of DSM III, the nosology of children and adolescents' disorders has evolved differently in Francophone and Anglo-Saxon countries. We want to 1 / familiarize readers with the nosographic concepts of mood disorders and bipolar disorders in the Francophone world of Adolescent Psychiatry; 2/ highlight the major current issues of concern to both Francophone and Anglo-Saxon adolescents' psychiatrists.

METHOD

A review of the literature in PubMed, PsycINFO and PsycARTICLES, but also of Francophone journals or textbooks not included in these databases nor distributed outside Francophone countries.

RESULTS

Although Francophone adolescents' psychiatrists still rely on the DSM II, particularly in reference to the transitory dimension of problems during adolescence, the DSM III led to a tightening of criteria for bipolar disorder in the Anglo-Saxon countries. These disorders have become rare in the 2000s while still common in Francophone countries. Nowadays the evolution of current criteria in Anglo-Saxon countries tends to bring the diagnostic criteria closer to the Francophone's one even though important differences still persist.

CONCLUSION

Despite differences between these two approaches in Psychiatry, there is agreement regarding the poor prognosis of type I bipolar disorder, particularly when psychotic traits are observed. Early diagnosis and treatment are therefore a challenge for both, but their limitations are inherent to their respective approaches. In Anglo-Saxon countries, if the criteria are met for bipolar disorder, treatment is decided at the risk of over-diagnosis and stigmatization of false positives. In Francophone countries, even if the criteria for bipolar disorder are met, it is still necessary that the psychopathological analysis of the disorder in the developmental framework of adolescence confirms that the disorder is stable, at the risk of later treatment and of increase of insufficiently treated false negatives. A reconciliation of these fields may limit the above side effects.

[Is my child normal, doctor? The specifics of child psychiatric examination]

The psychiatric assessment of a child requires to integrate the symptoms presented, for example, the child's suffering, in an array of complex family interactions The consultation process is difficult for parents and child, but also for the physician. Many pitfalls exist for everyone, namely the stigma attached to a disease, the search for normality at any price, the seduction of a reductive explanatory theory, and especially the oversight of the child's evolutionary potential. Finally, the characteristics of examination vary at each age; the differences may be major and depend on the development of the child in the process of empowerment.

Classroom based cognitive behavioural therapy in reducing symptoms of depression in high risk adolescents: pragmatic cluster randomised controlled trial

OBJECTIVE

To compare the effectiveness of classroom based cognitive behavioural therapy with attention control and usual school provision for adolescents at high risk of depression.

DESIGN

Three arm parallel cluster randomised controlled trial.

SETTING

Eight UK secondary schools.

PARTICIPANTS

Adolescents (n=5030) aged 12-16 years in school year groups 8-11. Year groups were randomly assigned on a 1:1:1 ratio to cognitive behavioural therapy, attention control, or usual school provision. Allocation was balanced by school, year, number of students and classes, frequency of lessons, and timetabling. Participants were not blinded to treatment allocation.

INTERVENTIONS

Cognitive behavioural therapy, attention control, and usual school provision provided in classes to all eligible participants.

MAIN OUTCOME MEASURES

Outcomes were collected by self completed questionnaire administered by researchers. The primary outcome was symptoms of depression assessed at 12 months by the short mood and feelings questionnaire among those identified at baseline as being at high risk of depression. Secondary outcomes included negative thinking, self worth, and anxiety. Analyses were undertaken on an intention to treat basis and accounted for the clustered nature of the design.

RESULTS

1064 (21.2%) adolescents were identified at high risk of depression: 392 in the classroom based cognitive behavioural therapy arm, 374 in the attention control arm, and 298 in the usual school provision arm. At 12 months adjusted mean scores on the short mood and feelings questionnaire did not differ for cognitive behavioural therapy versus attention control (-0.63, 95% confidence interval -1.85 to 0.58, P=0.41) or for cognitive behavioural therapy versus usual school provision (0.97, -0.20 to 2.15, P=0.12).

CONCLUSION

In adolescents with depressive symptoms, outcomes were similar for attention control, usual school provision, and cognitive behavioural therapy. Classroom based cognitive behavioural therapy programmes may result in increased self awareness and reporting of depressive symptoms but should not be undertaken without further evaluation and research.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN19083628.

First-psychotic episode in childhood and adolescence

INTRODUCTION

Psychosis in childhood and adolescence are defines as having delusions or hallucinations, with the hallucinations occurring in the absence of insight into their pathological nature. A broader definition includes symptoms such as disorganised speech and grossly disorganised or catatonic behavior. Negative symptoms such as alogia, amotivation and anhedonia can be present. Cognitive and mood symptoms may also be present. There are relatively few epidemiological studies on child and adolescent onset psychosis. It is generally held that the incidence of psychosis, and especially of schizophrenia, increases markedly during the teenage years, with a preponderance of male over female patients.

AIM

This is a descriptive review of child and adolescents with psychotic symptoms. It aims to describe their clinical profile, associated risk factors and management strategies utilised.

RESULTS

While psychotic disorders are considered rare in children and adolescents, they may severely affect development and long-term functioning. Early identification and intervention are critical to improving outcome. This review suggests that a considerable number of adolescents presenting with psychosis required lengthy periods of inpatient care.

CONCLUSION

There is often diagnostic uncertainty in the first episode of child and adolescent-onset psychosis. Key diagnostic issues relate to distinguishing schizophrenia from bipolar disorder in psychotic adolescents. The differential diagnosis may include psychotic disorder due to a general medical condition, or a substance-induced psychotic disorder.

Contemporary characteristics of the developmental age psychopathology

At present time, it may seem that the available therapeutic possibilities and methods have resulted in lower prevalence, and even disappearance, of certain psychopathological entities. The advancement of therapeutic methods has made possible to tackle new issues that are emerging in developmental psychopathology. These issues are directly related to the specifics of the current social sphere, reflecting the turbulent social changes as consequences of globalization and economic instability in the world. Humanitarian crises are ever more often accompanied by increased prevalence of mental disorders and psychological distress of the population in general. Based on child psychiatrists' reports from all corners of the globe, it is evident that the features of developmental psychopathology are constantly changing. The research studies refer to social events and phenomena that in previous decades were not to be found at the fore of clinical entities distribution. Thus, there are research reports on personality disorders in developmental age. Some thirty years ago, opinions were still divided on whether or not there existed personality disorders in developmental age. Nowadays, however, it is an accepted fact among experts that these disorders in youth warrant attention. This prevailing view has instigated research in this domain and now projects are carried out in many countries, so it is safe to say that the research has become global. Furthermore, the researchers' pay much attention to the problem of suicide both in youth and in children. Some special areas of research are being identified, such as the suicide risk assessment in adolescents undergoing short term antidepressant therapy. Latest data show that researchers are more often engaged in parent education, teaching them behaviours they need to raise a child with hyperactivity syndrome. Also, research results on the quality of emotional relationship with adoptive parents have been published with increasing frequency, especially by American authors. The results show that social services are detecting more and more cases of abuse of adopted children. Psychosomatic illnesses and liaison therapy at paediatric wards also feature prominently in current psychopathology. They are followed by issues of mental health of populations in humanitarian crises, including war, hard physical labour and abuse of child labour. The presentation includes a brief overview of psychopathology from the local perspective, with latest examples from clinical practice. The presentation concludes with the constatation that peculiarities of child and adolescent psychopathology follow the dynamic corresponding to the global social changes and increasing economic problems.

The copycat phenomenon after two Finnish school shootings: an adolescent psychiatric perspective

BACKGROUND

Two school shootings with altogether 18 victims took place in Finland in November 2007 and September 2008. Homicides and suicides are both associated with the copycat phenomenon. The aim of the present study was to characterize adolescent copycats who had threatened to carry out a school massacre.

METHODS

The nation-wide study evaluated 77 13- to 18-year-old adolescents who were sent for adolescent psychiatric evaluations between 8.11.2007 and 30.6.2009, one of the reasons for evaluation being a threat of massacre at school. The medical files of the copycats were retrospectively analysed using a special data collection form. Data on demographics, family- and school-related issues, previous psychiatric treatment and previous delinquency, current symptoms, family adversities and psychiatric diagnoses were collected. The severity of the threat expressed and the risk posed by the adolescent in question were evaluated. The Psychopathy Checklist Youth Version was used to assess psychopathic traits.

RESULTS

All of the copycats were native Finns with a mean age of 15.0 years. Almost two thirds of them had a history of previous mental health treatment before the index threat. Almost two thirds of the copycats suffered from anxiety and depressive symptoms, and almost half of the sample expressed either suicidal ideation or suicidal plans. Behavioural problems including impulse control problems, aggressive outbursts, the destruction of property as well as non-physical and physical violence against other persons were common. The diagnosis groups highlighted were behavioural and emotional disorders, mood disorders as well as schizophrenia-related disorders. The prevalence of pervasive developmental disorders was high. Only one of the copycats was assessed as expressing high traits of psychopathy.

CONCLUSION

The copycats with school massacre threats were characterized with a high prevalence of mental and behavioural disorders. Like actual school shooters, they showed psychotic symptoms and traumatic experiences, but unlike the shooters, the copycats were not psychopathic.

[Diagnostic difficulties in adolescent patients--subjective psychiatrist-side factors]

Adolescence is a period of intensive development and crucial transitions in human life. Developmental crises, oppositional behaviours and non-adaptive patterns are strengthened. Simultaneously some symptoms of mental disorders appear mostly in poor organised, non-specific prodromal syndromes. In these unstable and developmentally modified conditions psychiatric diagnosis and treatment seems to be very difficult. In the paper, we described the influence of countertransference of the psychiatrist on the diagnostic processes, especially the influence of a psychiatrist's adolescence on his/her unconscious attitude to adolescence at all.

Attuned Practice: a service user study of specialist child and adolescent mental health, UK

Aims – Best practice emphasises user involvement. This exploratory study addresses the views of teenage clients and their parents on service delivery in a specialist Child and Adolescent Mental Health Service (CAMHS) serving a population of 250,000. It aims to explore some of the complexities inherent in children's services when parents are integral to modes of treatment. Methods — Twenty-seven teenage clients from specialist CAMHS were recruited with their parents (n=30). All were white British, 11 boys and 16 girls, from a range of socioeconomic backgrounds. Focus groups were employed using a series of structured interactive technique to elicit information, preceded by home visits. Analysis of interview data followed standard approaches to qualitative data analysis. Descriptive statistics were generated from both home interview data and focus groups. Results – Three themes emerged: the core values implicated in establishing a therapeutic alliance; the style of therapy and mode of practice (i.e. its inclusiveness of different family members). Practice implications – Core therapeutic skills are of fundamental importance. Our paper supplements a model of organisational user involvement with a model of therapeutic user involvement for use in negotiating mode of practice. Conclusions – This exploratory study was a collaboration between service users, researchers and health professionals exploring three important themes of therapy and the complexities inherent in children's services. The process of eliciting views was therapeutic in itself leading to the formation of a parent-led self-help group. The design can be replicated in other specialist CAMHS to achieve attuned practice.

Declaration of Interest: none.

Psychotropic medication use in children and adolescents in an inpatient setting

Medication can be an effective part of treatment for several psychiatric disorders of childhood and adolescence but its use should be based on a comprehensive psychiatric evaluation and treatment plan. The aim of this study was to evaluate psychotropic medication use for children and adolescents treated as inpatients and to compare it with principles of rational pharmacotherapy, thus identifying possible downsides of current practices and pointing a way towards safer and more efficient practices. This is a descriptive study of prescribing trends at the Clinical Department for Children and Adolescents of the Institute of Mental Health in Belgrade, during the period from September 2009 to September 2010. Analyzed demographic data (age, gender) and the number of hospitalizations were obtained from medical histories, while diagnoses were obtained from discharge notes. Prescribed therapy was copied from medication charts. Drug dosages were analyzed as average daily doses prescribed during the hospitalization. Psychiatric diagnoses were classified according to The International Classification of Diseases and Related Health Problems, 10th Revision (ICD-10). During the examined time period, 264 patients were hospitalized (61.4% males), with an average age of 11.4±5.1 years. We have found that 66.3% of admitted patients were treated with pharmacotherapy in addition to other treatment modalities. There was a highly significant correlation between the age of patients and the prescribed dosage (Spearman's rho=0.360, p<0.001) as well as the number of prescribed drugs (Spearman's rho=0.405, p<0.001). The most commonly diagnosed psychiatric disorders were: autism spectrum disorders (20.8%), conduct disorders(19.7%), mixed developmental disorder (14.8%), adjustment disorder (7.2%), mental retardation (7.2%),acute psychosis (4.5%), and ADHD (2.3%). The most commonly prescribed medications were antipsychotics(45.9%), followed by antidepressants (17.2%), mood stabilizers (16.1%), benzodiazepines (14.4%), and other psychotropic drugs (6.4%). The most commonly prescribed antipsychotic was risperidone, used for more than 50% of the patients treated with antipsychotics. Taken together risperidone and chlorpromazine were more than 75% of all prescribed antipsychotics. 98.4% of prescribed antidepressants belonged to the SSRIs,with sertraline and fluoxetine accounting for almost 90% of them. All prescribed dosages were in accordance with the official guidelines. This is the first survey in Serbia to document the practice of prescribing psychotropic medication in the field of child and adolescent psychiatry. Current drug-prescribing practices at the Clinical Department for Children and Adolescents of the Institute of Mental Health in Belgrade are in accordance with current practices in the United States and Europe. Not every child with symptoms of mental health problems needs pharmacological treatment; when they do, the general rule of thumb should be "start low, go slow, and taper slowly". Follow-up studies are necessary to assess the change of trends, as well as studies in different patient populations and health centers, in order to globally evaluate psychotropic medication use in children and adolescents in Serbia.

Implementation of problem-based learning in child and adolescent psychiatry: shared experiences of a special-interest study group

BACKGROUND/OBJECTIVE

Problem-based learning (PBL) represents a major development and change in educational practice that continues to have a large impact across subjects and disciplines worldwide. It would seem that child and adolescent psychiatry, because of its inherently integrative, bio-psycho-social nature and emphasis on teamwork and collaboration, would be a specialty learned optimally through PBL. Thus, there was a need to establish an international group where experiences in implementing PBL in child and adolescent psychiatry could be shared. This article reports on the first meeting and plans of the Problem-Based Learning in Child and Adolescent Psychiatry (CAP) Special Interest Study Group (SISG), held at the annual meeting of the American Academy of Child and Adolescent Psychiatry.

METHODS

Through international collaboration and information-sharing, the SISG aims to promote knowledge among Child and Adolescent Psychiatrists on PBL, to explore evaluation methods of PBL in CAP, and to discuss development of PBL-based curricula.

RESULTS

Problem-based learning (PBL) represents a major change in education that has had a large impact across disciplines worldwide.

CONCLUSION

The core steps in PBL are the following: presentation of the initial problem; discussion of the problem, and development of learning objectives; independent learning focused on the objectives; and discussion, exploration of new ideas, and discovery of solutions in the reconvened group. Different from the traditional teacher's role, the PBL tutor is an active facilitator who guides learners to identify issues and ways to learn, rather than a "content expert" who provides facts.

Psychiatry trainees' training and experience in fetal alcohol spectrum disorders

BACKGROUND/OBJECTIVE

Alcohol is a teratogen. Fetal alcohol spectrum disorders (FASDs) affect about 1% of live births, causing severe impairment. Individuals affected by FASDs are overrepresented in psychiatric settings. This study reports on the education and experience of psychiatry trainees in approaching FASDs.

METHOD

Data were collected from psychiatry trainees throughout the country by use of a web-based questionnaire.

RESULTS

A representative sample (N=308) of psychiatry trainees responded; 19% rate their education on FASDs as "good" or "excellent," and 89% report that they would like more education on FASDs: 6%, 15%, and 30%, endorsed the statement "It is safe to drink some alcohol" during the 1st, 2nd, and 3rd trimesters, respectively. Only 31% correctly report that individuals with an FASD are at equal risk for adverse outcomes as individuals with full-blown fetal alcohol syndrome.

CONCLUSIONS

results reveal that training on FASDs is inadequate. Psychiatry trainees poorly understand the importance of abstinence throughout pregnancy. Trainees who report receiving supervision specifically addressing FASDs also report making the diagnosis much more frequently, suggesting that supervision in clinical settings is effective teaching. Results reveal that FASDs are underrecognized, resulting in missed opportunities for prevention and intervention.

A pilot study of social competence group training for adolescents with borderline intellectual functioning and emotional and behavioural problems (SCT-ABI)

BACKGROUND

Emotional and behavioural problems as well as a lack of social competence are common in adolescents with borderline intellectual functioning and impair their social and vocational integration. Group interventions specifically developed for this target group are scarce and controlled evaluation studies are absent.

METHODS

A cognitive-behavioural group training (Social Competence Training for Adolescents with Borderline Intelligence) was developed and its effectiveness was examined in students attending special vocational schools. A total of 77 adolescents with borderline intelligence were randomised either to the intervention (n=40) or to the control group (n=37). Outcome measures at post-treatment and at a 6-month follow-up comprised self-reports, caregiver reports and behavioural observations.

RESULTS

The adolescents in the intervention group showed temporally stable improvement in their social competence, especially in social problem solving (F=17.6, P<0.001) and attainment of individual behavioural goals in everyday life (self-reports: F=15.9, P<0.001; caregiver reports: F=87.9, P<0.001). Effects of the intervention on other outcomes such as problem-solving competence and skills performed in standardised role plays were weak or absent.

CONCLUSIONS

Social Competence Training for Adolescents with Borderline Intelligence is a promising treatment for adolescents with borderline intellectual functioning and associated emotional/behavioural symptoms. Further studies examining long-term effects on the participants' social and vocational integration are needed.

Cognitive behavioural therapy and young people: an introduction

Cognitive behavioural therapy (CBT) is a form of psychotherapy or "talking cure" that has been shown to be effective for a wide range of psychological problems and shows promise in many others. Up to now it has been used more with adults but there is a growing body of evidence of its usefulness in children and young people for conditions that include depression, generalised anxiety disorder, obsessive compulsive disorder, school phobia, eating disorders, self-harm and conduct problems.

Practitioner review: adolescent alcohol use disorders: assessment and treatment issues

BACKGROUND

Alcohol use disorders in adolescents are associated with significant morbidity and mortality. Over the past decade, there has been a burgeoning of research on adolescent alcohol use disorders.

METHODS

A summary of the alcohol assessment tools is provided, and randomized studies reviewed and synthesized to provide an overview of state of the art knowledge of treatment of adolescent alcohol use disorders. Animal models of addiction are also briefly reviewed, and the value of translational research approaches, using findings from basic studies to guide the design of clinical investigations, is also highlighted.

RESULTS

Comorbidity is the rule, not the exception in adolescent alcohol use disorders. Comprehensive assessment of psychiatric and other substance use disorders, trauma experiences, and suicidality is indicated in this population to optimize selection of appropriate clinical interventions. In terms of available investigated treatments for adolescents with alcohol use disorders, Multidimensional Family Therapy and group administered Cognitive Behavioral Therapies have received the most empirical support to date. There is a paucity of research on pharmacological interventions in this patient population, and no firm treatment recommendations can be made in this area.

CONCLUSIONS

Given the high rate of relapse after treatment, evaluation of combined psychosocial and pharmacological interventions, and the development of novel intervention strategies are indicated.

Reinventing family therapy: teaching family intervention as a new treatment modality

OBJECTIVE

This article discusses the pedagogy of teaching family therapy in the new millennium. It draws on the strengths of "family systems therapy" but goes beyond it-suggesting a new paradigm, new terminology, and a new teaching perspective. It discusses the historical background of family therapy training, a scientific foundation for what residents should be taught, and an integrative clinical model for how it could be taught.

METHODS

The article is the synthesis of the perspectives and experience of a child and adolescent psychiatrist educator who began his career at the end of the systemic era in psychiatry and continues it through the developments of the neurobiologic era. It draws on selected literature from the fields of family therapy, child and adolescent psychiatry, developmental psychopathology, and general psychiatry.

RESULTS

This article submits that the term "family therapy" should be replaced by the term "family intervention"; the evidence base indicates that family interventions are effective; family risk and protective factors influence the onset and course of disorders; families help shape and maintain cognitive schema; intervention must start with thorough case formulation; and family interventions should be coordinated with other interventions, include parent management training, and build on family strengths.

CONCLUSION

Family intervention is an important clinical process in child and adolescent psychiatry, and contemporary education must address the multiple ways clinicians can assist families. Future models will be successful to the degree they build on the past contributions of systems thinking and include the perspectives of developmental psychopathology. Contemporary education should teach that family interventions are not optional but ideally can be integrated with other interventions in a sequential manner, emphasizing the interrelationship between self and system.

Implementation of MET/CBT 5 for adolescents

Implementation of effective substance abuse treatment programs in community settings is a high priority. The selection of a proven cost-effective model is a first step; however, difficulty arises when the model is imported into a community setting. The Center on Substance Abuse Treatment selected a brief substance abuse treatment program for adolescents, the MET/CBT-5 program, determined to be the most cost-effective protocol in the Cannabis Youth Treatment trial, for implementation in two cohorts of Effective Adolescent Treatment grantees. A qualitative investigation of the protocol implementation with nine sites in the second cohort chronicled adaptations made by grantees and prospects for sustainability. The study found that agencies introduced adaptations without seeming to be aware of potential effects on validity. In most sites, sessions were lengthened or added to accommodate individual client needs, address barriers to client participation, and provide consistency with current norms of treatment. Implications for fidelity of future implementation projects are addressed.

Videoconferencing in child and adolescent psychiatry in Finland--an inadequately exploited resource

To assess the current role of videoconferencing and the purposes for which it has been used in child and adolescent psychiatry in Finland, we sent a 16-item questionnaire to all providers of child and adolescent psychiatry services in specialised health care in Finland, i.e. the 42 child and adolescent units in 21 hospital districts. All service providers responded. The responses to both open-ended and structured questions were analysed manually and classified quantitatively and qualitatively. Use of videoconferencing was reported by 16 of the 21 hospital districts in Finland. Videoconferencing had been used for more than 5.5 years in only three hospital districts, for 3-5 years in 14 units and for 1-3 years in six units. Videoconferencing was used for clinical work in 12 and for distance education in another 12 hospital districts. Videoconferencing was used weekly for clinical work and for supervision by two districts; it was used for education by three districts. Although the workers' experiences of and attitudes towards videoconferencing were favourable, it has not been widely used in child and adolescent psychiatry. The implementation of videoconferencing seems to depend more on the activity of service providers than on the number of people involved.

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.

Transparent criteria for specialist level adolescent psychiatric care

BACKGROUND

Rising health care costs and long waiting lists pose a challenge to public specialist level health services. In Finland, the Ministry of Social Affairs and Health required all medical specialities to create a priority-rating tool for elective patients, preferably giving a numerical rating ranging 0-100, with 50 as an entry threshold.

OBJECTIVE

To create and test the psychometric properties of a point-count measure for prioritising entry to public specialist level adolescent psychiatric services.

METHOD

Around 710 referred adolescents were given ratings on 17 items focusing on symptom severity, problem behaviours, functioning, progress of adolescent development and prognosis. The structured ratings were compared to an overall assessment of need for treatment on a VAS scale. In order to ensure that the tool was not inappropriately sensitive to confounding by non-disturbance related factors, the associations between the structured priority rating and sex, age, referring agent, study site and diagnosis were analysed.

RESULTS

Of the 17 items, 15 were included in the final priority-rating tool. The requirement than threshold score for entry to services being set at 50 points necessitated scoring factors rather than individual items. Four blocks of items were formed: symptoms and risks; impaired functioning; other relevant issues, and prognosis without specialist level treatment. Most of the referred adolescents scored over the threshold of 50. When diagnosis was controlled for, scoring over 50 was largely independent of age, sex, referring agent or study site.

CONCLUSION

The structured priority ratings corresponded well with clinical global rating of need for care. The tool was not inappropriately sensitive to age, sex, referring agent or study site. In the future, follow-up studies will be needed to evaluate the predictive value of priority ratings.

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.

Recent non-medication trials of interpersonal psychotherapy for depression

Interpersonal psychotherapy (IPT) is a time-limited treatment described in a manual and tested in numerous clinical trials, with and without medication. Four recent clinical trials are reviewed in situations where medication as a first-line treatment for depression was not feasible (pregnancy, post partum, adolescence and in a developing country). The results show the efficacy of 12-16 wk of IPT compared to treatment as usual or no treatment in reducing depressive symptoms. The therapists providing the treatment included psychiatrists, psychologists, social workers as well as non-mental-health workers. We do not know if these patients might have done even better with medication, but each study showed a significant remission of symptoms of patients in IPT compared to controls. The use of efficacious, time-limited psychotherapy, which can be administered by non-medical personnel can be economical. An obstacle to providing evidence-based psychotherapies is the paucity of practitioners trained in them. Until the gap between training in psychotherapy and the research evidence in psychotherapy is bridged in training programmes, it will be difficult to provide patients with these treatments.

Umgang mit jugendlichen Patienten zur Erfassung von Noxen in der Adoleszenz

Der altersangemessene Umgang mit jugendlichen Patienten ist eine wichtige Voraussetzung für die Erfassung der Einwirkung von Noxen in der Adoleszenz. Das Angebot zu einem Gespräch mit dem Arzt allein, die Zusicherung des eingeschränkten Patientengeheimnisses auf Wunsch hin auch gegenüber den Eltern sowie eine nicht urteilende Haltung des Arztes sind wichtige vertrauensfördernde Elemente für die erfolgreiche Gesprächsführung über den Konsum von psychoaktiven Substanzen und andere potentiell auf die jugendliche Person einwirkende Noxen. Um das Patientengeheimnis auch gegenüber den Eltern wahren zu können, sind die Urteilsfähigkeit der jugendlichen Person sowie mögliche Selbst- und Fremdgefährdung abzuklären. Das wiederholte Gespräch mit jugendlichen Patienten über potentielle Noxen in der Adoleszenz sollte ein fester Bestandteil der Arztkonsultation bilden, um einen Beitrag zur umfassenden Gesundheitsförderung zu leisten.

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.

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.