Perceptions of seclusion and restraint by patients and staff in an intermediate-term care facility.

PROBLEM: Little of clinical relevance has been derived from research studies conducted on seclusion and restraint. Most studies elicit staff, as opposed to patient, views of the restraint event. METHODS: Content analysis, descriptive statistics of debriefing incidents (N = 81) following the initiation of seclusion and restraint from both patient and staff perspectives. FINDINGS: Patients and staff had varied views of the restraint incidents, but overall they were closer in their perceptions of precipitants and what could have been done to prevent the incident. CONCLUSIONS: Debriefing incidents can be used as learning tools for staff and patients, to track staff and patient progress, and as a way to change the culture of psychiatric settings.

Case study: chewing gum treatment of rumination in an adolescent with an eating disorder.

Rumination occurs frequently in children and adolescents with eating disorders, but few studies or case reports consider rumination an associated symptom. Fewer address related treatment issues. The authors describe successful treatment of rumination in a 16-year-old female adolescent using postmeal chewing gum. Rumination should be considered in youngsters with bulimia or anorexia nervosa, and approaches to its treatment should be studied.

The impact of legislation to improve coordination of services to children with serious emotional disturbance.

OBJECTIVE: This study evaluated the impact of state legislation in Indiana mandating establishment of local coordinating committees to prevent inappropriate placement of children and youth with serious emotional disturbance out of the home and to facilitate the development of communitybased initiatives. METHODS: In the first stage of the study, a survey was sent to the directors of mental health, welfare, education, and probation agencies of each county to estimate the extent that the structure and processes mandated by law were in place. In the second stage, structured interviews were conducted with the directors of key agencies in seven representative counties. RESULTS: Stage 1 produced 310 completed surveys from all 92 counties; 73 counties had functioning committees. Improved coordination among providers was the most frequently cited reason for the committee's success; half of the respondents felt that the committee resulted in better services. More than half reported that too few service options were available. Other problems cited were rigid funding opportunities that limited options and lack of staff time to attend and prepare for meetings. Interviewees in the second stage noted that the committee too often formalized already-made decisions, that consideration of individual cases came too late in the process, and that in many cases less restrictive options had already been tried unsuccessfully. They also noted that the committee process had not achieved its major objective of pooling resources to address the needs of particular children. CONCLUSIONS: Adequate funding and a fiscal strategy to support coordination and staffing of local coordinating committees are critical to their successful implementation.

Psychiatric diagnoses in the child and adolescent members of extended families identified through adult bipolar affective disorder probands.

OBJECTIVE: To investigate the type and distribution of psychiatric disorders in the child and adolescent members of extended pedigrees identified through bipolar probands. METHOD: The child and adolescent offspring (24 male, 26 female, aged 6 to 17 years) and the adult parents (60) of 14 bipolar pedigrees ascertained for the National Institutes of Mental Health Genetics Initiative Study of Bipolar Affective Disorder were personally assessed using structured psychiatric interviews. A parent was also interviewed about each child or adolescent offspring. RESULTS: Twelve of the 50 interviewed offspring received a lifetime DSM-III-R diagnosis of an affective disorder. This included six cases of bipolar disorder, five cases of major depressive disorder, and one case of dysthymia. Eight of the offspring who received an affective disorder diagnosis also qualified for an anxiety disorder (four), a disruptive behavior disorder (two), or both (two). Offspring who had a parent with an affective disorder had a 5.1-fold higher risk for receiving an affective disorder diagnosis than did offspring with healthy parents. CONCLUSIONS: In a consecutive series of families identified through a proband with bipolar disorder, there were significant increases in the prevalence of affective disorder diagnoses in the child and adolescent offspring. The distribution of illness in offspring was compatible with the presence of important genetic factors which contribute to early-onset affective illness.

The cyclic dilemma: organic, functional, and environmental interaction in a young teenager.

This Grand Rounds considers an early-adolescent female who demonstrated a mixed clinical picture including rapid cycling of psychotic behavior. The case presents issues commonly faced in hospital practice and provides an example of the use of standardized instruments in assessment and monitoring treatment, as well as a discussion of issues germane to inpatient child and adolescent psychiatrists and related treatment team members.

Fluoxetine-induced memory impairment in an adolescent.

This paper describes a 14-year-old male patient who complained of memory problems during treatment with fluoxetine for major depression. The patient showed impairments on all five scales of the Wechsler Memory Scale-Revised during fluoxetine treatment. Three of the scales, Verbal Memory, Visual Memory, and General Memory, showed statistically significant improvements after fluoxetine was discontinued. This case represents the first time memory deficits related to fluoxetine were quantitated with a standardized memory test. It points to cognitive side effects that need to be understood.

A consultative study as a catalyst for improving mental health services for rural children and adolescents.

The consultative study is one model of academic involvement in public mental health services. However, the effects of consultation and how it acts as a catalyst for change have been poorly documented. The authors describe a consultative study in which a team from a academic training center examined the system of mental health and related human services for children and adolescents in a semirural county in western Pennsylvania. They also present results of a six-year follow-up survey assessing the study's effects. Improvement in the system of care during the follow-up period included creation and maintenance of a children's unit and a partial hospital program for adolescents at the country's community mental health center. The consultative study and the follow-up survey were instrumental in establishing a comprehensive range of services, including intensive case management for severely disturbed youngsters and a home-based mental health services program.

State-university collaboration to enhance public psychiatric services in western Pennsylvania.

A collaboration established in 1974 between the Pennsylvania State Office of Mental Health and Western Psychiatric Institute and Clinic of the University of Pittsburgh Medical Center provides a comprehensive program of continuing mental health education, skills development, and program consultation to state hospitals and publicly funded community programs in rural and semirural western Pennsylvania. The authors describe the development of the program and discuss its current organization and activities. In 1990-91 a total of 60 faculty and 150 staff members from the institute contributed more than 1,200 hours of direct programming. The collaboration's activities have broadened in both hospital and community sectors and currently involve all of the university's health and medical care schools.

Patient assessment and treatment planning in child and adolescent partial hospital programs.

Thirty-six patient records were examined during site visits to 18 child and adolescent (PH) programs. The documentation of patient assessment and treatment planning was examined. The history of present illness, past psychiatric history, and medical history were at least adequate in about 60-70% of evaluations. Treatment plans were generally complete, but at least one-half of mandated treatment plan reviews lacked revisions. Psychiatric justification of admission and diagnosis was poor in 41% and 44% of charts, respectively, and there was no documentation of ongoing psychiatrist-patient contact in 44% of charts. Possible explanations for these findings include inadequate funding of PH programs, lack of psychiatric time, and uniform approaches to treatment.

Borderline disorders of childhood: an overview.

This selected review considers children classified as "borderline" and focuses on two broad categories: Borderline personality disorder/borderline spectrum and schizotypal personality disorder/autism/schizophrenia spectrum classifications. Clinical descriptions, biological correlated, delimitation from other disorders, outcome, family studies, hypothesized etiologies, therapeutic considerations, and response to treatment are presented for each. Data support the subclassification of the heterogeneous groupings of borderline children into at least the two categories, and their differentiation from each other and from other clinical disorders in the population. Overlap across the borderline categories exists for individual children. The nature and shortcomings of relevant studies are described, the need for scientifically based research championed, and a differential approach to directive treatment of borderline children advocated. Further subclassification of borderline disorders should result in more cost-effective diagnosis and treatment.

Clinical and demographic characteristics of child and adolescent partial hospital patients.

Eighteen child and adolescent partial hospital (PH) programs were surveyed through site visits. Demographic and diagnostic characteristics of 796 patients and clinical records of current and discharged patients were examined. Most current patients lived with relatives and 52% received Medicaid. Fifty-eight percent had a primary diagnosis of an externalizing disorder and 46% had been hospitalized. Forty percent of the former patients (N = 96) were discharged from PH when such services were no longer needed; another 36% left because of lack of improvement. Administrative implications of these findings are discussed.

Training child psychiatrists in rural public mental health.

Lack of appropriate training in both public mental health service and rural mental health service is a major factor in the critical shortage of child psychiatrists in rural settings. The authors describe a residency training program in rural public mental health designed to help alleviate that shortage. The program familiarizes fourth-year residents in child psychiatry with the clinical, political, and social aspects of rural public mental health services through didactic and supervisory sessions as well as an eight-month practicum experience involving provision of inservice training and administrative and case-related consultation to staff of mental health agencies. An assessment of the program indicated that participants felt it was beneficial, but the program was only partly successful in increasing the number of child psychiatrists entering practice in rural areas. The authors urge that residency programs in child psychiatry give priority to training child psychiatrists for work in rural settings.

Self-report and interview measures of childhood and adolescent depression.

Childhood and adolescent depression has received increased attention in recent years, both in clinical research and practice. Evaluation of depression has been facilitated by the emergence of several self-report and interview measures designed to assess severity of depression. The present paper reviews these measures, including their characteristics, advantages and limitations. Salient considerations raised by current measures include inconsistencies in the range of symptoms they encompass, potential limitations of self-report, influences of age and age-related variables, and reliability of the measures. The validity of alternative measures is reviewed by examining the extent to which criteria for construct, content, criterion, convergent and discriminant validation are met. Recommendations are provided for areas of research to further validate measures of depression for children and adolescents.