Can we distinguish the consequences of early maltreatment on child behaviour from idiopathic autism?

OBJECTIVE: To identify clinical features that could distinguish children presenting with autistic-like features and a history of severe early maltreatment from children with idiopathic autism spectrum disorders (ASDs). DESIGN: Matched-comparison study. SETTING: Great Ormond Street Hospital, UK. PARTICIPANTS: 46 children with a history of early maltreatment, mean (SD) age 10.6 (3.3) years and 47 children with an ASD, mean (SD) age 10.4 (2.9) years. MAIN OUTCOME MEASURES: A range of standardised interview and observational measures that are designed to quantify autistic traits. Caregiver and teacher reports were obtained on broader aspects of behavioural and emotional adjustment. RESULTS: Both groups had normal range IQ and were predominantly male. On the basis of autistic traits alone, caregiver interview and structured observation concurred that over 60% of the formerly maltreated children met criteria for an ASD. Autistic symptom profiles were very similar in both groups, although children with idiopathic ASD had significantly more marked repetitive and stereotyped behaviours. Teacher and caregiver reports indicated that children from both groups had an increased and broadly similar prevalence of emotional and behavioural disorders. CONCLUSION: Children presenting with a history of early maltreatment, who show autistic traits of behaviour, have a high risk of meeting diagnostic criteria for ASD. Their symptom profiles are virtually indistinguishable from children with idiopathic autism.

Assessing autism spectrum disorder in children with a background of maltreatment: challenges and guidance.

There may be some similarities in the presentation of children who have autism spectrum disorder (ASD) and those exposed to maltreatment affecting assessment and diagnosis. Overlapping characteristics include difficulties understanding and maintaining relationships, sensitivity to routine and hyper-reactivity to sensory inputs. Children who have been maltreated are at increased risk of various developmental vulnerabilities with both environmental and genetic factors being relevant. The existing epidemiological evidence has found that looked-after children are more likely to screen positively for neurodevelopmental disorders and there are smaller scale studies in adoptive children finding higher rates of ASD than would be expected in the general population. Other research suggests a predominantly genetic basis for this increased risk in keeping with what is generally understood about the aetiology of autism. Children exposed to profound deprivation in Romanian orphanages were found to be at higher risk of a pattern of traits termed 'quasi autistic' which tended to reduce following adoption, but these findings have not been replicated in children experiencing maltreatment in birth families. Reactive attachment disorder (RAD) has some overlapping criteria with ASD, but its prevalence is unknown and children with RAD should be more socially reciprocal and not have the same repetitive and restricted behaviours and interests. We recommend experienced multidisciplinary assessment that considers both the possibility of maltreatment in children with ASD and neurodevelopmental vulnerabilities in children who have been maltreated and advise on assessment and management strategies.

Emotional abuse and neglect in a clinical setting: challenges for mental health professionals.

This article addresses some of the common uncertainties and dilemmas encountered by both adult and child mental health workers in the course of their clinical practice when dealing with cases of suspected emotional abuse or neglect (EAN) of children. We suggest ways of dealing with these according to current best practice guidelines and our own clinical experience working in the field of child maltreatment.

Guided self-help interventions for mental health disorders in children with neurological conditions: study protocol for a pilot randomised controlled trial.

BACKGROUND: Rates of mental health disorders are significantly greater in children with physical illnesses than in physically well children. Children with neurological conditions, such as epilepsy, are known to have particularly high rates of mental health disorders. Despite this, mental health problems in children with neurological conditions have remained under-recognised and under-treated in clinical settings. Evidence-based guided self-help interventions are efficacious in reducing symptoms of mental health disorders in children, but their efficacy in reducing symptoms of common mental health disorders in children with neurological conditions has not been investigated. We aim to pilot a guided self-help intervention for the treatment of mental health disorders in children with neurological conditions. METHODS/DESIGN: A pilot randomised controlled trial with 18 patients with neurological conditions and mental health disorders will be conducted. Participants attending specialist neurology clinics at a National UK Children's Hospital will be randomised to receive guided self-help for common mental health disorders or to a 12-week waiting list control. Participants in the treatment group will receive 10 sessions of guided self-help delivered over the telephone. The waiting list control group will receive the intervention after a waiting period of 12 weeks. The primary outcome measure is reduction in symptoms of mental health disorders. Exclusion criteria are limited to those at significant risk of harm to self or others, the presence of primary mental health disorder other than anxiety, depression or disruptive behaviour (e.g. psychosis, eating disorder, obsessive-compulsive disorder) or intellectual disability at a level meaning potential participants would be unable to access the intervention. The study has ethical approval from the Camden and Islington NHS Research Ethics Committee, registration number 14.LO.1353. Results will be disseminated to patients, the wider public, clinicians and researchers through publication in journals and presentation at conferences. DISCUSSION: This is the first study to investigate guided self-help interventions for mental health problems in children with neurological conditions, a group which is currently under-represented in mental health research. The intervention is modular and adapted from an empirically supported cognitive behavioural treatment. The generalisability and broad inclusion criteria are strengths but may also lead to some weaknesses. TRIAL REGISTRATION: Current Controlled Trials: ISRCTN21184717 . Registered on 25 September 2015.

Children after adoption: Exploring their psychological needs.

Children adopted from care are known to be at increased risk for mental health difficulties although relatively little research has been carried out to explore this question. This study assessed the mental health and psychological development of children placed for adoption by one UK Local Authority. We compared the pattern and prevalence of difficulties to existing data including that on Looked-After Children (LAC) children. Totally, 106 families were initially approached and parent interviews and at least partial questionnaire data were gathered on 47 children, 72.3% of whom were known to have been maltreated prior to adoption. Of the 34 children with a complete data set including Development and Well-Being Assessment (DAWBA), 76.4% met full criteria for at least one neurodevelopmental or mental health diagnosis, a markedly higher rate than comparison data on LAC or community samples. Less than half of those identified with a mental health diagnosis had received any prior diagnosis, and only a minority had received appropriate services. Despite the children's difficulties, the great majority of parents reported high enjoyment of bringing up their child.

Contact refusal by children following acrimonious separation: therapeutic approaches with children and parents.

This paper aims to build on the existing literature, by presenting some thoughts based on clinical experience with nine families of children referred for intractable contact refusal with one parent following marital separation. This particular group of high-conflict divorce cases engenders an inordinate amount of frustration both within the courts and therapeutic agencies. We outline here our assessment process and therapeutic strategies, as well as consideration of the role of the wider professional system and the courts. We conclude that whether or not direct contact with the rejected parent is achieved, useful therapeutic work can be carried out to assist children in moving on with their lives.

Some reflections on the use of psychiatric diagnosis in the looked after or "in care" child population.

The current classification system, DSM-IV, inadequately captures the range and type of psychopathology seen in the "in care" population of children. A combination of pre-natal influences, early interpersonal trauma involving the primary caregiving relationship, disturbed and disrupted attachment relationships and other significant losses and adverse environmental effects produce a complex constellation of symptoms and a pervasive impact on development that is difficult to categorize. The challenges facing DSM-V are illustrated, highlighting unresolved topics such as quasi-autism, reactive attachment disorder and complex trauma.

Citalopram to treat depression in pediatric oncology.

We describe the first four cases of an open-label study investigating the response to citalopram in a depressed pediatric oncology population. Advice from the Committee for Safety of Medicines (CSM) in the United Kingdom warning against the use of serotonin-selective reuptake inhibitor (SSRI) antidepressants other than fluoxetine in this age group led to the discontinuation of the study. Advantages of citalopram over fluoxetine in a medical setting are discussed in terms of its favorable drug-interaction profile and shorter half-life. Citalopram was very well tolerated in these patients and preliminary data are presented that support its efficacy as an antidepressant agent in these patients.

Depression in paediatric cancer: an overview.

Research into depression in paediatric cancer is in its early stages, but nevertheless has presented interesting challenges regarding the recognition and measurement of depression in a medically ill population. In this article we discuss the complex interaction between physical and psychological variables, and the diagnostic difficulties arising from this. We review the epidemiological findings regarding prevalence, evaluating the apparently low prevalence rate in the light of methodological weaknesses. Hypotheses put forward to explain the findings are discussed. We conclude by highlighting areas for future research.