Emotional impact of genetic trials in progressive paediatric disorders: a dose-ranging exon-skipping trial in Duchenne muscular dystrophy.

BACKGROUND: Gene-modifying trials offer hope for improvement in chronic paediatric disorders, but they may also lead to disappointment and have an adverse emotional effect on families. This study aimed to examine emotional impact on participants in a paediatric exon-skipping trial. METHODS: Nineteen male children with Duchenne muscular dystrophy (DMD), and their parents, taking part in a dose-ranging study of an i.v. administered morpholino splice-switching oligomer (which can restore the reading frame in DMD and induce dystrophin expression) underwent a psychosocial/psychiatric examination at trial entry. Emotional impact was assessed at trial completion using questionnaires. RESULTS: The mean child age was 8.9 years (SD 2.1); 13(68%) were attending mainstream school. Most families were well adjusted psychosocially at trial entry. Post-trial median child emotional impact scores were 5/10 (n= 18), but impact was rated as positive by 6/14 (42%), neutral/mixed by 5 (35%) and negative by 3 (21%). Median post-trial psychosocial/psychiatric change scores in children and parents were minimal. Actual post-trial negative impact was statistically significantly associated with higher expected impact at trial entry, at which time the families of the three children displaying actual negative impact reported higher family stress levels in combination with a variety of other psychosocial risks factors. CONCLUSIONS: In carefully selected families with low levels of psychosocial stress/distress at trial entry, and with good support from paediatric research units (including psychiatric input when required), genetic trials in progressive disorders such as DMD can have a predominantly positive or neutral emotional impact. Nevertheless, negative impact is reported by a minority of families and possible psychosocial predictors deserving further scrutiny have been identified.

Depressive symptoms and behavioural health risks in young women attending an urban sexual health clinic.

BACKGROUND: Adolescence is a time of increased health risk behaviours and depressive symptoms and disorders. Most young people with depressive disorders, however, are not under the care of specialist child and adolescent mental health services, and there is increasing interest in identifying alternative appropriate settings which are acceptable for young people and may attract those at high risk for depressive disorders. AIM: To assess depressive and behavioural health risks in attendees to a sexual health clinic (SHC) for young people. METHOD: Cross-sectional controlled study of women attending a SHC and school attendees, using questionnaires on depressive symptoms and mental health problems, sexual activity and substance use. RESULTS: 115/178 attendees 14-19 years old completed questionnaires. In the comparison between 66 women aged 16-18 years and 49 socio-demographically group-matched school controls, SHC attendees reported higher levels of sexual activity and substance use. They were significantly more at risk for depression (20/65 or 30% vs. 4/46 or 8%; chi(2)P < 0.01) on the Beck Depression Inventory, for emotional (12/66 or 18% vs. 1/49 or 2%; chi(2)P < 0.01), hyperactivity (11/66 or 16% vs. 2/46 or 4%; chi(2)P < 0.05) and conduct (8/66 or 12% vs. 0/49; chi(2)P < 0.05) problems on the Strengths and Difficulties Questionnaire. High depressive scores were significantly associated with a history of self-harm, earlier alcohol use and having tried cannabis, but not with sexual risk behaviours. Earlier age at first sexual intercourse was linked to higher sexual and substance use risks. CONCLUSION: We have found high levels of depressive symptoms among attendees to a SHC for young people, which seem an appropriate setting for screening and providing guidance for depression and other health risk behaviours.

Self-esteem in child and adolescent psychiatric patients.

Self-esteem is a widely used term in psychiatric referrals. It has been shown to be impaired in various physical and psychological disorders and to be improved by treatment. The availability in recent years of an easy-to-use questionnaire and normative data from a community study make measurement of self-esteem and comparison between clinical and community populations possible. The Harter Modified Self-Esteem Questionnaire was given at first clinic appointment to 132 children aged 8-15 years. Mean scores were calculated within six domains of self-esteem and compared within age and gender groupings with community data and across diagnostic groups. Self-esteem was lower in the clinical than community sample, especially in Global and Scholastic domains. Reductions in self-esteem scores were most striking in adolescent boys and in emotional/ psychosomatic disorders. Clinic girls had lower Physical Appearance self-esteem than clinic boys. We conclude that psychopathology severe enough to lead to clinic referral was associated with lowered self-esteem. Specific domains were affected in line with symptomatology, which has implications for treatment.

Psychiatric adjustment in chronic fatigue syndrome of childhood and in juvenile idiopathic arthritis.

BACKGROUND: High rates of psychopathology and of personality problems have been reported in children and adolescents with chronic fatigue syndrome (CFS). It is not clear whether this is consequent on the experience of chronic physical ill health. We compare psychiatric adjustment in children with CFS and in children suffering from another chronic physical disorder (juvenile idiopathic arthritis or JIA). METHOD: Our sample consisted of 28 children with CFS and 30 with JIA attending tertiary paediatric centres (age range, 11 to 18 years, mean 15, S.D. 2.3). In order to assess psychiatric status and functioning, we used the K-SADS psychiatric interviews, CGAS and Harter Self-Esteem Questionnaire with child subjects; behavioural questionnaires (CBCL) and child personality assessment interviews (PAS) with parent informants. RESULTS: Psychiatric disorders in the year prior to interview had been present significantly more commonly in the CFS group (72% v. 34% in JIA) and were more impairing to them (CGAS scores of 45 v. 77). Most common diagnoses in both groups were depressive and anxiety disorders. Personality problems were also significantly more frequent in CFS subjects (48% disorder and 26% difficulty v. 11% and 11% in JIA). There were few differences between the two groups in self-esteem. CONCLUSIONS: Psychopathology and personality problems are common in children and adolescents with severe forms of CFS and cannot be explained strictly through the experience of chronic physical illness.

Psychiatric adjustment to leaving school in adolescents with intellectual disability: a pilot study.

The negotiation of stressful life cycle transitions may contribute to the higher prevalence of psychiatric disorders amongst people with intellectual disability (ID). It is possible that leaving school at the age of 16 years might place particular psychological demands on adolescents, increasing the risk of psychiatric morbidity at a time when they are vulnerable as a result of losing the links with health services sustained through school attendance. The present pilot study was designed as a prospective cohort study to investigate whether there is an increase of psychiatric morbidity [rated with the Strengths and Difficulties Questionnaire (SDQ), and through semi-structured interviews with parents] in adolescents with ID at the time of their transition from school to adult education and services. Although there was a high frequency (eight out of 10 subjects) of reported emotional and behavioural problems prior to transition, there was no increase or decrease in psychiatric morbidity for the group as a whole during the 6 months after leaving school. However, there were marked individual differences in scores on the SDQ, which may be worth investigating in a larger study.

Child and adolescent mental health service use. HoNOSCA as an outcome measure.

BACKGROUND: HoNOSCA (Health of the Nation Outcome Scales for Children and Adolescents) is a recently developed measure of outcome for use in child and adolescent mental health services (CAMHS). AIMS: To examine HoNOSCA's sensitivity to change, convergent validity and clinical usefulness. METHOD: Prospective study of new CAMHS attenders. Questionnaires completed by clinicians, parents and referrers at initial assessment and after 6 months. RESULTS: Follow-up HoNOSCAs on 203 children indicated statistically significant change. There were significant associations between change in HoNOSCA scores, changes in other clinician- and parent-rated scales (r = 0.51 to 0.32) and in global outcome ratings by referrers, parents and clinicians. Intraclass correlation coefficients for the summated HoNOSCA scores were high. HoNOSCA change was positively correlated with initial HoNOSCA score (r = 0.46, P < 0.001) and it was linked to psychiatric diagnosis. CONCLUSIONS: HoNOSCA is a sensitive, valid measure of change among CAMHS attenders.

The course of severe chronic fatigue syndrome in childhood.

Little has been reported on prognostic indicators in children with chronic fatigue syndrome (CFS). We used interviews with children and parents, a mean of 45.5 months after illness onset, to follow up 25 cases of CFS referred to tertiary paediatric psychiatric clinics. At its worst, the illness had been markedly handicapping (prolonged bed-rest and school absence in two-thirds); mean time out of school was one academic year. Two-thirds, however, had recovered and resumed normal activities--mean duration of illness to recovery/assessment 38 months--and none had developed other medical conditions. Recovery was associated with specific physical triggers to the illness, with start of illness in the autumn school term and with higher socioeconomic status. Severe fatigue states in children can cause serious and longlasting handicap but most children recover.

Practitioner review: Assessment and management of somatisation in childhood and adolescence: a practical perspective.

The assessment and treatment of somatisation in childhood require explicit recognition that many families frequently hold strong belief in the presence of physical disorders. Engaging the family, recognising and focusing on their beliefs and concerns, and paediatric/psychiatric liaison are usually required. Our knowledge on the management of children with somatisation is largely based on clinical reports but a number of open trials and methodologically increasingly stronger studies show that somatisation can respond to family treatments involving cognitive-behavioural techniques as well as to sensitive, psychologically sound advice by paediatricians. Antidepressants should be considered when there are comorbid mood disorders.

Maternal expressed emotion and adjustment in children with epilepsy.

Epilepsy in childhood may alter family relationships but the relevance of these changes for the increased rates of psychopathology has been little investigated. This study uses maternal expressed emotion (EE) to examine family relationships of children with epilepsy and the association with high risk for psychiatric disorder. EE was assessed using the Camberwell Family Interview carried out with the mothers of 22 schoolchildren with chronic epilepsy who were attending a general hospital outpatient clinic. Sixteen of these children had similarly aged healthy siblings who served as controls. High risk for psychiatric disorder in the children and mothers was assessed using behavioural, mood, and self-esteem questionnaires completed by mothers, teachers, and children. It was found that mothers showed significantly more emotional overinvolvement and a trend for more hostility towards their children with epilepsy than towards sibling controls. For the 22 children with epilepsy, maternal emotional overinvolvement was not associated with child behavioural deviance. High levels of criticism and, to a lesser extent, hostility did show associations with child behavioural deviance, and the strongest links were between maternal criticism and maternal rated antisocial and overactive behaviour in the child. Fewer positive comments by mothers towards the children were associated with child emotional symptoms and lower self-esteem in a number of areas. This study suggests that further research could consider the appropriateness of psychological intervention for families in which mothers are critical and hostile and whose children show antisocial behaviour.

Children with psychiatric disorders who are frequent attenders to primary care.

Child psychiatric disorder has been found to be linked to enhanced primary care attendance. We studied the somatic and psychological associations of psychiatric disorder amongst frequent (four or more consultations a year) primary care attending school children. We compared 32 children aged 7-12 years with a psychiatric disorder with 77 non-disordered (also frequently attending) children. Psychiatric disorder was not associated with type of presenting complaint at the surgery nor with chronic physical illness. However disordered children were more likely to be described by their mothers as handicapped by existing physical problems, in poor health, with low energy levels and likely to experience physical symptoms under stress. Problems in social relationships and educational difficulties were reported in more disordered children; more of them came from broken homes and had mothers who reported other psycho-social and health stresses and showed characteristic health beliefs. The findings indicate that knowledge about the child's general physical well-being and relationships and about maternal mental health may assist in the primary care identification and management of psychiatric disorders of frequently attending schoolchildren.

Paddington Complexity Scale and Health of the Nation Outcome Scales for Children and Adolescents.

BACKGROUND: There is an increasing interest in measuring health care outcomes in mental health services for children as well as adults. AIMS: We examined the sensitivity of the Paddington Complexity Scale (PCS) and the Health of the Nation Outcome Scales for Children and Adolescents (HoNOSCA) in describing the intakes of child and adolescent mental health clinics. METHOD: We carried out a prospective study of two out-patient units and one day patient unit, by means of questionnaires administered to clinicians, parents and children. RESULTS: Clinician-rated PCS and HoNOSCAs were obtained for 248 new attenders. Both proved sensitive to intake differences between clinics. There were correlations of moderate intensity (r = 0.6) between total PCS and HoNOSCA. There were weaker associations between these and parent/child rated measures of behaviour (r = 0.4 and 0.3), quality of life and self-esteem (r = 0.3 or less). CONCLUSIONS: Both PCS and HoNOSCA are useful for describing clinical profiles of children and adolescents receiving mental health services.

Psychiatric disorders in adolescents in primary care.

BACKGROUND: Little is known about psychiatric disorders in adolescents who attend primary care. METHOD: Prospective study of 13- to 16-year-olds consecutively attending general practice. Information was obtained from adolescents, parents and general practitioners, using questionnaires and research interviews. RESULTS: 136/200 (68%) of adolescent attenders took part. Two per cent presented with psychiatric complaints. From research interviews with adolescents, psychiatric disorder in the previous year was found in 38%, with moderate impairment of functioning in over half (according to Children's Global Assessment Scale scores). Most disorders (42/50, 84%) were emotional ('internalising') disorders. Psychiatric disorders were significantly associated with high levels and intensity of physical symptoms and with increased health risks. General practitioner assessment of psychiatric disorders was low on sensitivity (20.8%) but high on specificity (90.7%). Doctors identified most severely affected adolescents. CONCLUSIONS: Depressive and anxiety disorders are common among adolescent general practice attenders and linked to increased physical symptoms; general practitioner recognition is limited.

School attendance and juvenile chronic arthritis.

We studied the school attendance of 113 children and adolescents (mean age 11 yr, S.D. 3.8, range 3-18 yr) with juvenile chronic arthritis (73 with pauci- and 40 with polyarthritis). The mean attendance rate for the group was 92% (equivalent to 15 absent days a year) with a median of 97%. Attendance was significantly lower in the more severely affected poly group (90% vs 98% in the pauci group; P = 0.03). We found associations of school absence (i) with decreased compliance with physical treatments (r = -0.35, P < 0.05 for compliance with physiotherapy) in the poly group and (ii) with child psychological deviance (r = 0.36 for parentally rated and r = 0.42 for teacher-rated psychological deviance; both P < 0.05) in the pauci group. We conclude that school attendance can be good in severely affected children. Severity of illness, treatment compliance and psychological problems in the child may affect school attendance.

Survey of difficult to contain and treat children and adolescents.

Child psychiatrists and paediatricians are faced by a number of disturbed children and adolescents who become a major treatment challenge due to a combination of their dangerous and/or disruptive behaviour and the unavailability of resources. Paediatricians and psychiatrists in one regional health area were questioned about the number of such children and adolescents under 18 years of age seen over a 20 month period. The response rate was 44% (86/194 specialists approached). A total of 72 children and adolescents were identified. For a health district with a total population of 200,000, this represents nearly five children (about one of these identified by paediatricians and one with associated learning disability). The majority of cases were adolescents with chronic problems (over one month's duration) but most cases reported by paediatricians were acute in preadolescents. Conduct disorders, autistic spectrum, and psychotic disorders were the most common clinical problems. Seriously disruptive behaviour had been present in two thirds and marked problems with behaviour that was a physical risk to others and to the self were present in over half and nearly a third of cases respectively. Services had been universally stretched by these children's difficulties. Clinicians thought the needs of these children would have been best met either through psychiatric day hospital type facilities or in combined paediatric/child psychiatric inpatient units.

Somatisation in children.

This review summarises recent work on somatisation in childhood. Minor physiological dysfunction may play a part in a number of cases and associated psychiatric disorders are commonly though not universally found. Contributory family factors include high rates of health problems and of parental psychological distress and there is some evidence for the role of family modelling and reinforcement of illness behaviour. There is suggestive evidence linking somatisation to emotional closeness in families, to family togetherness around health matters and to anomalies in children's social relationships. Somatisation in children can respond to treatments involving cognitive-behavioural and family techniques as well as to sensitive, psychologically sound advice from paediatricians.

Psychiatric intervention in primary care for mothers whose schoolchildren have psychiatric disorder.

BACKGROUND: Psychiatric disorder in schoolchildren has been linked to increased general practice attendance rates. This increase may, in part, be a result of maternal stress focused on the disturbed child, and of a decrease in confidence in parenting. AIM: A study was undertaken to pilot the feasibility of a single session, psychiatric intervention in primary care for mothers of disturbed children and to examine uptake rates and reported immediate and long-term effects. METHOD: Single psychiatric sessions by a child psychiatrist in general practice were offered to mothers of 26 schoolchildren. The schoolchildren (age range 7-12 years, mean nine years) were frequent attenders in general practice with physical symptoms, and were identified from research interviews carried out with a parent (usually their mother) as psychiatrically disordered. The main outcome measures were the mothers' ratings of helpfulness of the intervention; degree of behavioural, emotional or health problems in their children and confidence in managing them; the Rutter A parental behaviour questionnaire; and children's yearly general practice attendance rates. RESULTS: Sixteen mothers (62%) who were offered appointments attended for the intervention. Nine of the 14 who responded at three-month follow up (64%) reported that the intervention had been markedly or extremely helpful. The main areas of perceived improvement at both three months and at 18-24 months were in the child's behaviour, emotional and health problems, and in the mother's confidence in dealing with these. Mothers also found the specific advice discussed and the ability to talk to somebody about the problems helpful. Mothers were less likely to find the intervention extremely or markedly useful where the child had had previous psychiatric intervention. The mean yearly attendance rate for the whole group of 23 children (data missing for three) decreased from 6.5 consultations before the intervention to 2.8 afterwards; there was a non-significant trend for the drop in attendance to be more marked in the group whose mothers attended the intervention and who felt helped by it, than among the group of children whose mothers only reported finding the intervention slightly useful. CONCLUSION: Standardized child psychiatric interventions which may be used in the primary care setting appear acceptable and may be helpful to mothers in addressing psychiatric disorders associated with somatic presentation in their schoolchildren.

Psychiatric adjustment in children with chronic physical illness.

Improved medical treatments for children with chronic illness have resulted in better survival rates as well as more morbidity and use of medical resources by ill children. Increasingly, interest is being directed at the implications of illness for the child's quality of life and psychiatric adjustment.