Living on Site While Renovating; Flexible Instructional Design of Post-Graduate Medical Training

Background

Developing theoretical courses for post-graduate medical training that are aligned to current workplace-based learning practices and adaptive to change in the field is challenging, especially in (sub) specialties where time for re-design is limited and needs to be performed while education continues.

Approach

An instructional design method was applied based on flexible co-design to improve post-graduate theoretical courses in child and adolescent psychiatry (CAP) in the Netherlands. In four phases over a period of three years, courses were re-designed at a national level.

Evaluation

Once common vision and learning goals were agreed upon and the prototype was developed (phases 1 and 2), the first courses could be tested in daily practice (phase 3). Phase 4 refined these courses in brief iterative cycles and allowed for designing additional courses building on and adding to previous experiences in brief iterative cycles. The resulting national theoretical courses re-allocated resources previously spent on a local level using easily accessible online tools. This allowed trainees to align content with their clinical rotations, personal preferences and training schedules.

Reflection

The development of theoretical courses for post-graduate medical training in smaller medical (sub-)specialties with limited resources may profit from a flexible instructional design method. We consider the potential merit of such a method to other medical specialties and other (inter-)national efforts to develop theoretical teaching courses. A longer-term implementation evaluation is needed to show to what extent the investment made in the re-design proves to be future-proof and enables rapid adaptation to changes in the field.

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.

Putative shared mechanisms in autism spectrum disorders and attention deficit hyperactivity disorder, a systematic review of the role of oxidative stress

Oxidative stress is now believed to play a crucial role for neurodevelopment disorders such as autism spectrum disorders (ASD) and attention deficit hyperactivity disorder (ADHD). To review the most recent literature regarding the role of oxidative stress for the pathophysiology of ASD and ADHD, we conducted a systematic search of the relevant literature and further discuss the clinical and research implications of this knowledge. A systematic search in PubMed database retrieved 132 articles, of which 33 were included in the review. This review found relevant evidence concerning the role of oxidative status in ASD and ADHD, albeit with some contradictory findings. In order to overcome the incongruities found, more studies are needed in the study of neurodevelopmental disorders, with more thorough study designs and particular attention to the accuracy of the diagnostic tools used for the cases included.

[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.

[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.

Editorial: Bayesian benefits for child psychology and psychiatry researchers

For many scientists, performing statistical tests has become an almost automated routine. However, p-values are frequently used and interpreted incorrectly; and even when used appropriately, p-values tend to provide answers that do not match researchers' questions and hypotheses well. Bayesian statistics present an elegant and often more suitable alternative. The Bayesian approach has rarely been applied in child psychology and psychiatry research so far, but the development of user-friendly software packages and tutorials has placed it well within reach now. Because Bayesian analyses require a more refined definition of hypothesized probabilities of possible outcomes than the classical approach, going Bayesian may offer the additional benefit of sparkling the development and refinement of theoretical models in our field.

Annual Research Review: Building a science of personalized intervention for youth mental health

BACKGROUND

Within the past decade, health care service and research priorities have shifted from evidence-based medicine to personalized medicine. In mental health care, a similar shift to personalized intervention may boost the effectiveness and clinical utility of empirically supported therapies (ESTs). The emerging science of personalized intervention will need to encompass evidence-based methods for determining which problems to target and in which order, selecting treatments and deciding whether and how to combine them, and informing ongoing clinical decision-making through monitoring of treatment response throughout episodes of care. We review efforts to develop these methods, drawing primarily from psychotherapy research with youths. Then we propose strategies for building a science of personalized intervention in youth mental health.

FINDINGS

The growing evidence base for personalizing interventions includes research on therapies adapted for specific subgroups; treatments targeting youths' environments; modular therapies; sequential, multiple assignment, randomized trials; measurement feedback systems; meta-analyses comparing treatments for specific patient characteristics; data-mining decision trees; and individualized metrics.

CONCLUSION

The science of personalized intervention presents questions that can be addressed in several ways. First, to evaluate and organize personalized interventions, we propose modifying the system used to evaluate and organize ESTs. Second, to help personalizing research keep pace with practice needs, we propose exploiting existing randomized trial data to inform personalizing approaches, prioritizing the personalizing approaches likely to have the greatest impact, conducting more idiographic research, and studying tailoring strategies in usual care. Third, to encourage clinicians' use of personalized intervention research to inform their practice, we propose expanding outlets for research summaries and case studies, developing heuristic frameworks that incorporate personalizing approaches into practice, and integrating personalizing approaches into service delivery systems. Finally, to build a richer understanding of how and why treatments work for particular individuals, we propose accelerating research to identify mediators within and across RCTs, to isolate mechanisms of change, and to inform the shift from diagnoses to psychopathological processes. This ambitious agenda for personalized intervention science, although challenging, could markedly alter the nature of mental health care and the benefit provided to youths and families.

The Internal, External, and Diagnostic Validity of Sluggish Cognitive Tempo: A Meta-Analysis and Critical Review

OBJECTIVE

To conduct the first meta-analysis evaluating the internal and external validity of the sluggish cognitive tempo (SCT) construct as related to or distinct from attention-deficit/hyperactivity disorder (ADHD) and as associated with functional impairment and neuropsychological functioning.

METHOD

Electronic databases were searched through September 2015 for studies examining the factor structure and/or correlates of SCT in children or adults. The search procedures identified 73 papers. The core SCT behaviors included across studies, as well as factor loadings and reliability estimates, were reviewed to evaluate internal validity. Pooled correlation effect sizes using random effects models were used to evaluate SCT in relation to external validity domains (i.e., demographics, other psychopathologies, functional impairment, and neuropsychological functioning).

RESULTS

Strong support was found for the internal validity of the SCT construct. Specifically, across factor analytic studies including more than 19,000 individuals, 13 SCT items loaded consistently on an SCT factor as opposed to an ADHD factor. Findings also support the reliability (i.e., internal consistency, test-retest reliability, interrater reliability) of SCT. In terms of external validity, there is some indication that SCT may increase with age (r = 0.11) and be associated with lower socioeconomic status (r = 0.10). Modest (potentially negligible) support was found for SCT symptoms being higher in males than females in children (r = 0.05) but not in adults. SCT is more strongly associated with ADHD inattention (r = 0.63 in children, r = 0.72 in adults) than with ADHD hyperactivity-impulsivity (r = 0.32 in children, r = 0.46 in adults), and it likewise appears that SCT is more strongly associated with internalizing symptoms than with externalizing symptoms. SCT is associated with significant global, social, and academic impairment (r = 0.38-0.44). Effects for neuropsychological functioning are mixed, although there is initial support for SCT being associated with processing speed, sustained attention, and metacognitive deficits.

CONCLUSION

This meta-analytic review provides strong support for the internal validity of SCT and preliminary support for the external validity of SCT. In terms of diagnostic validity, there is currently not enough evidence to describe SCT in diagnostic terms. Key directions for future research are discussed, including evaluating the conceptualization of SCT as a transdiagnostic construct and the need for longitudinal research.

Editorial: Looking beyond the horizon--innovation in child psychology and psychiatry

As readers will no doubt be well aware, the Journal of Child Psychology and Psychiatry dedicates an entire issue, once a year, to state-of-the-art authoritative reviews of research on some of the central issues in our field.(1) I like to think that in doing so we have been quietly undertaking a giant Pavlovian conditioning experiment: every year, as the spring flowers start to blossom (in the northern hemisphere at least), the nucleus accumbens of child psychologists and psychiatrists around the world begin to glow in anticipation of intellectual reward.

From Family Therapy to Family Intervention

For many, family therapy refers to sessions in which all family members are present. Yet in contemporary psychiatry there are many ways to work with families in addition to this classic concept. This article proposes family intervention as an encompassing term for a new family paradigm in child and adolescent psychiatry. Developmental psychopathology is a guiding principle of this paradigm. A full range of ways to work with families clinically is described with clinical examples.

[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.

Editorial: bridging gaps between basic research and clinical practice

Over the past several decades, child psychology and psychiatry has witnessed an explosion in the volume of, and a decided quickening in the pace of, dissemination of research findings. On the one hand, this has led us to an enviable position.

Diagnosis and evaluation of hallucinations and other psychotic symptoms in children and adolescents

Recognizing positive psychotic symptoms and their diagnostic context in youth is challenging. A large minority say they "hear things others do not hear," though they seldom present with complaints of hallucinations or delusions. Few have schizophrenia spectrum disorder, but many have other psychiatric disorders. Frequently, they have psychotic symptoms for an extended period before diagnosis. Clinicians should understand psychotic symptoms and their differential diagnoses. This article reviews the epidemiology, associated diagnoses, and prognosis of hallucinations and delusions in youth. Strategies for optimizing the clinical diagnostic interview, appropriate laboratory tests, indications for psychological testing, and rating scales are reviewed.

[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.

Harnessing innovative technologies to advance children's mental health: behavioral parent training as an example

Disruptive behaviors of childhood are among the most common reasons for referral of children to mental health professionals. Behavioral parent training (BPT) is the most efficacious intervention for these problem behaviors, yet BPT is substantially underutilized beyond university research and clinic settings. With the aim of addressing this research-to-practice gap, this article highlights the considerable, but largely unrealized, potential for technology to overcome the two most pressing challenges hindering the diffusion of BPT: (1). The dearth of BPT training and supervision opportunities for therapists who work with families of children with disruptive behaviors; and (2). The failure to engage and retain families in BPT services when services are available. To this end, this review presents a theoretical framework to guide technological innovations in BPT and highlights examples of how technology is currently being harnessed to overcome these challenges. This review also discusses recommendations for using technology as a delivery vehicle to further advance the field of BPT and the potential implications of technological innovations in BPT for other areas of children's mental health are discussed.

[Gender identity disorder and related sexual behavior problems in children and adolescents: from the perspective of development and child psychiatry]

The present paper reviews the theoretical and empirical literature on children and adolescents with gender identity disorder. The organizational framework underlying this review is one that presents gender behavior in children and adolescents as a continuum rather than as a dichotomy of normal versus abnormal categories. Theories of normative gender development, prevalence, assessment, developmental trajectories, and comorbidity were investigated. There is a greater fluidity and likelihood of change in the pre-pubertal period. It was reported that the majority of affected children had been eventually developing a homosexual orientation. As an approach to determine the prevalence of GID in clinical samples in our child psychiatry clinic, screening instruments that include items on cross-gender or cross-sex identification were used. We applied the Child Behavior Checklist (CBCL). Of the 113 items in the Japanese version of the CBCL, there are two measures of cross-gender identification: "behaves like opposite sex" and "wishes to be opposite sex." Like the other items, they are scored on a 3-point scale of: 0-not true, 1- somewhat true, and 2-very true. Our study of 323 clinically-referred children aged 4-15 years reported that, among the boys, 9.6% assigned a score of 1 (somewhat true) or a score of 2 (very true) to the two items. The corresponding rates for the clinically-referred girls were 24.5%. The item of diagnosis of GID in our clinical sample was significantly higher than in non-referred children, reported as 2-5% using the same method. Two clinical case histories of screened children are also presented. Both of them were diagnosed with PDDNOS. Together with the literature review, most of the gender-related symptoms in autistic spectrum disorders (ASD) could be related to the behavioral and psychological characteristics of autism as shown in case histories. ASD subjects in adolescence can sometimes develop a unique confusion of identity that occasionally exaggerates to gender-related problems. However, these views do not explain all cases; true comorbidity of ASD and GID should be considered. A full assessment including evaluation of the family, school, and social environment is essential as other emotional and behavioral problems are very common and unresolved issues in the child's environment are often present e. g., loss. Separation problems are particularly common in the younger group. Intervention should aim to assist development, particularly that of gender identity. It should focus on ameliorating the comorbid problems and difficulties in the child's life and reducing the distress experienced by the child.

Predictors of diagnosis of child psychiatric disorder in adult-infant social-communicative interaction at 12 months

To establish which social interactive behaviours predict later psychiatric diagnosis, we examined 180 videos of a parent-infant interaction when children were aged one year, from within the Avon Longitudinal Study of Parents and Children (ALSPAC) cohort. Sixty of the videos involved infants who were later diagnosed with a psychiatric disorder at seven years, and 120 were a randomly selected sex-matched control group. Interactive behaviours for both the caregiver and the one year old infant were coded from the videos according to eight holistic categories of interpersonal engagement: Well-being, Contingent Responsiveness, Cooperativeness, Involvement, Activity, Playfulness, Fussiness, and Speech. Lower levels of adult activity and speech in interaction at one year significantly predicted overall diagnosis of child psychiatric disorder.

[Validation of the Hungarian version of the Strengths and Difficulties Questionnaire in an adolescent clinical population]

INTRODUCTION

The short Strengths and Difficulties Questionnaire (SDQ) available in parent, teacher and self-report versions, is used world-wide for assessing and screening childhood behavior and mental problems, as part of clinical assessments, therapy outcome evaluations, and research tool. The aim of the present study was to extend the use of Hungarian version to a clinical sample, to examine the clinical cut-off values suggested previously on the basis of a normative sample, and to test the questionnaire's sensitivity in differentiating between different psychiatric disorders.

METHOD

The parent and self-report versions of the five scale SDQ-Magy questionnaire was filled in by 716 parents and their children admitted to Vadaskert Child Psychiatry and Outpatient Clinic. Clinical (ICD) diagnoses were determined during psychiatric examination.

RESULTS

With a few exceptions, internal consistencies of the scales were satisfactory (0,55-0,79), the parent version showing greater reliability compared to the self-report version. Children's age, gender, and parents' level of education had some effect on the scale scores. The questionnaire's Total problem and symptom scale scores were very effective in discriminating between the control and the clinical sample. In the clinical sample, parents rated their children's behavior and mental problems as more severe. Profiles of scale scores distinguished the wider internalizing, externalizing, and co-morbid diagnostic categories, as well as the eight specific diagnoses. Based on the normal-abnormal cut-off values proposed earlier (Turi et al., 2011), the great majority of clinical cases were screened by the questionnaire.

CONCLUSIONS

The Hungarian version of the SDQ proved applicable in a clinical sample. Psychometric properties, variances due to age, gender and informant were consistent with international experiences. SDQ profiles related to clinical diagnoses and their difference from the control group show the sensitivity and discriminative power of the questionnaire, while the screening ability based on clinical cut-offs also supports the clinical use of the questionnaire.

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.

Annual research review: re-thinking the classification of autism spectrum disorders

BACKGROUND

The nosology of autism spectrum disorders (ASD) is at a critical point in history as the field seeks to better define dimensions of social-communication deficits and restricted/repetitive behaviors on an individual level for both clinical and neurobiological purposes. These different dimensions also suggest an increasing need for quantitative measures that accurately map their differences, independent of developmental factors such as age, language level and IQ.

METHOD

Psychometric measures, clinical observation as well as genetic, neurobiological and physiological research from toddlers, children and adults with ASD are reviewed.

RESULTS

The question of how to conceptualize ASDs along dimensions versus categories is discussed within the nosology of autism and the proposed changes to the DSM-5 and ICD-11. Differences across development are incorporated into the new classification frameworks.

CONCLUSIONS

It is crucial to balance the needs of clinical practice in ASD diagnostic systems, with neurobiologically based theories that address the associations between social-communication and restricted/repetitive dimensions in individuals. Clarifying terminology, improving description of the core features of ASD and other dimensions that interact with them and providing more valid and reliable ways to quantify them, both for research and clinical purposes, will move forward both practice and science.

Comparison of ICD-10 and DC: 0-3R diagnoses in infants, toddlers and preschoolers

The purpose of this study was to analyze and compare diagnoses of patients from a special outpatient department for infants, toddlers and preschoolers. Specifically, overlap, age and gender differences according to the two classification systems DC: 0-3R and ICD-10 were examined. 299 consecutive children aged 0-5; 11 years received both ICD-10 and DC: 0-3R diagnoses. All ICD-10 diagnoses were given prospectively at the initial contact. The DC: 0-3R diagnoses were allotted in mutual consensus conferences. The most common ICD-10 disorders were Oppositional Defiant (ODD), Hyperkinetic (HKD) and Emotional Disorders. In DC: 0-3R, nearly half of the children could not be coded adequately ('Other Disorders'). Sleep Behavior Disorders were followed by Feeding Behavior and Regulation Disorders. Both classification systems are needed in infant, toddler and preschool psychiatry. There is a good concordance of the two systems for Feeding, Sleeping, Adjustment and Attachment Disorders, whereas the ICD-10 diagnoses HKD and ODD are not adequately represented in DC: 0-3R.

The validity of psychiatric diagnoses: the case of 'specific' developmental disorders

We tested whether developmental coordination disorder (DCD) and mixed receptive expressive language disorder (RELD) are valid diagnoses by assessing whether they are separated from each other, from other childhood disorders, and from normality by natural boundaries termed zones of rarity. Standardized measures of intelligence, language, motor skills, social cognition, and executive functioning were administered to children with DCD (n = 22), RELD (n = 30), autistic disorder (n = 30), mental retardation (n = 24), attention deficit/hyperactivity disorder (n = 53) and to a representative sample of children (n = 449). Discriminant function scores were used to test whether there were zones of rarity between the DCD, RELD, and other groups. DCD and RELD were reliably distinguishable only from the mental retardation group. Cluster and latent class analyses both resulted in only two clusters or classes being identified, one consisting mainly of typical children and the other of children with a disorder. Fifty percent of children in the DCD group and 20% in the RELD group were clustered with typical children. There was no evidence of zones of rarity between disorders. Rather, with the exception of mental retardation, the results imply there are no natural boundaries between disorders or between disorders and normality.

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.

Therapeutic uses of the WebCam in child psychiatry

OBJECTIVE

The authors provide examples for the use of the WebCam as a therapeutic tool in child psychiatry, discussing cases to demonstrate the application of the WebCam, which is most often used in psychiatry training programs during resident supervision and for case presentations.

METHOD

Six cases illustrate the use of the WebCam in individual and family therapy.

RESULTS

The WebCam, used during individual sessions, can facilitate the development of prosocial skills. Comparing individual WebCam video sessions can help to evaluate the effectiveness of medication and progress in therapy.

CONCLUSION

The WebCam has proven to be useful in psycho-education, facilitating communication, and treating children and families. The applications of this technology may include cognitive-behavioral therapy, dialectical-behavioral, and group therapy.