The mental health of young people in Australia: key findings from the child and adolescent component of the national survey of mental health and well-being.

OBJECTIVE: To identify the prevalence of three mental disorders (Depressive Disorder, Conduct Disorder and Attention-Deficit/Hyperactivity Disorder), the prevalence of mental health problems, the health-related quality of life of those with problems, and patterns of service utilisation of those with and without mental health problems, among 4-17-year-olds in Australia. To identify rates of health-risk behaviours among adolescents with mental health problems. METHOD: The mental disorders were assessed using the parent-version of the Diagnostic Interview Schedule for Children Version IV. Parents completed the Child Behaviour Checklist to identify mental health problems and standard questionnaires to assess health-related quality of life and service use. The Youth Risk Behaviour Questionnaire completed by adolescents was employed to identify health-risk behaviours. RESULTS: Fourteen percent of children and adolescents were identified as having mental health problems. Many of those with mental health problems had problems in other areas of their lives and were at increased risk for suicidal behaviour. Only 25% of those with mental health problems had attended a professional service during the six months prior to the survey. CONCLUSION: Child and adolescent mental health problems are an important public health problem in Australia. The appropriate balance between funding provided for clinical interventions focusing on individual children and families and funding for interventions that focus on populations, requires careful study. The latter are an essential component of any strategy to reduce mental health problems as the high prevalence of problems makes it unlikely that individual care will ever be available for all those needing help. Clinical and population health interventions must take into account the comorbid problems experienced by children with mental disorders.

Child sexual abuse I: psychopathology.

OBJECTIVE: To review scientific literature concerning the prevalence, childhood outcome and adult outcome of child sexual abuse, and the hypothetical models that have been postulated to explain its psychopathology. METHOD: Selective critical review of literature. RESULTS: Estimates of prevalence of sexual abuse suggest that a significant number of children of both sexes are affected. Research into the psychopathology of sexual abuse is hindered by methodological problems. However, sexual abuse has been associated with a number of psychiatric disorders and maladaptive lifestyles in childhood and adulthood. Several theoretical models of the psychopathology of child sexual abuse are examined and compared. CONCLUSIONS: A transactional model is the most comprehensive and encompassing.

Child sexual abuse II: treatment.

OBJECTIVE: To evaluate the scientific literature concerning the treatment of child sexual abuse. METHOD: A critical review of the scientific literature. RESULTS: There are only nine published research studies in which subjects were randomly assigned to an index treatment or treatments and a comparison treatment or no-treatment control group. In seven of the studies, the index treatment exceeded the control or comparison group in regard to treatment outcome; in two studies it did not. The successful treatments involved group therapy, combined individual and group play therapy and cognitive behaviour therapy. CONCLUSIONS: Treatment should be based on an explicit conceptual model of the psychopathology of sexual abuse. The University of Queensland Sexual Abuse Treatment Project, which is based on a transactional model, is described.

Postgraduate education in child and adolescent psychiatry.

The content of an ideal training program in child and adolescent psychiatry is summarized under the following headings: educational mission; general instructional foci, learning experiences; and evaluation. External and internal obstacles to the establishment and implementation of innovative training programs are discussed. A survey of past trainees was undertaken, and the topics which they considered should be emphasized more are listed. Finally, the paper predicts the issues which will emerge or gain in importance by 2000 AD.

The ritual abuse of children: clinical features and diagnostic reasoning.

A case of alleged ritual sexual abuse is presented. Clinical recognition and diagnostic reasoning are discussed. After a brief account of modern satanism, it is concluded that, although the evidence for the occurrence of ritual abuse is sketchy, a high index of suspicion is appropriate.

Seven-year outcome of the Vermont Intervention Program for Low-Birthweight Infants.

We compared 24 low-birthweight subjects of an experimental intervention (LBWE), 32 no-treatment controls (LBWC), and 37 normal birthweight (NBW) subjects. The intervention involved 7 hospital sessions and 4 home sessions in which a nurse helped mothers adapt to their LBW babies. At age 7, LBWE scored significantly higher than LBWC on the Kaufman Mental Processing Composite (p less than .001), Sequential (p = .02), and Simultaneous (p = .001) Scales, after statistical adjustments for socioeconomic status. LBWE did not differ from NBW (F less than 1). These results bear out a divergence between the LBWE and LBWC that first became statistically significant at age 3. The findings suggest that the intervention prevented cognitive lags among LBW children, and that long-term follow-ups are needed to evaluate the developmental effects of efforts to overcome major biological and environmental risks.

The Mother-Infant Transaction Program. The content and implications of an intervention for the mothers of low-birthweight infants.

A brief, economic neonatal intervention based on the transactional model of development and influenced predominantly by the conceptual design of the Neonatal Behavioral Assessment Scale was implemented in an intensive care nursery with the mothers of a group of low-birthweight infants. The development of the intervention group was compared with that of a similar group of low-birthweight infants who did not receive the intervention and contrasted with that of a group of normal-birthweight infants. The intervention had a significant effect on maternal adjustment and perception of the infant at 6 months. No significant effect on infant cognitive development was apparent until 36 months (that is, 31 months after the intervention had ceased). The intervention effect was even more significant at 48 months. It appeared that the two low-birthweight groups had progressively diverged after 12 months, the intervention group rising until it approximated the normal-birthweight group in cognitive development, whereas the low-birthweight control group deteriorated. The economical nature of the MITP, its unique (although delayed) benefits, and the apparent durability of the intervention effect, suggest that this intervention program has important theoretical and practical implications and potentially far-reaching applications.

Is major depressive disorder in childhood a distinct diagnostic entity?

One approach to validation of the construct of major depressive disorder in childhood was examined. Multivariate analyses of parents' responses on the Child Behavior Checklist (CBCL) were undertaken to determine whether a depressive symptom component would emerge and whether a group of children with pure depressive disorder could be isolated. The study involved 284 children (91 inpatients and 193 outpatients) aged 6 to 11 years. Principal components analyses identified a weak depression component among the CBCL items. Other components were aggressive, anxious, withdrawn, and immature. Cluster analyses designed to isolate a group of children with pure depressive disorder did not accomplish that goal. The results suggest that current enthusiasm for the diagnosis of major depressive disorder in children may be misplaced, and that a dimensional dysthymic syndrome that accompanies many other problems may better explain patterns of symptoms in children. The importance of the use of multiple methods to validate important psychiatric diagnoses is discussed.

Is major depressive disorder in adolescence a distinct diagnostic entity?

The concept of major depressive disorder in childhood and adolescence is reviewed and it is suggested that contemporary enthusiasm for this diagnosis may have outrun the evidence that it is a distinct categorical entity. To test the hypothesis that major depression is not a qualitatively distinct disorder in adolescence, but rather a continuously distributed, noncategorical syndrome, the behavioral rating scales (CBCL-P) of 216 hospitalized adolescent patients were analyzed first by principal components analysis and then by cluster analysis. Three behavioral syndromes were isolated by principal components analysis. Of three groups of patients identified by a subsequent cluster analysis, one was consistent with the concept of a categorically distinct "nuclear" depression. However, a noncategorical continuously distributed depressive syndrome appears to affect a larger number of patients in this age group, and the "nuclear" disorder may be less prevalent than is currently assumed. One explanation of these findings would combine a categorical model of nuclear depression with a dimensional model of dysthymia.

Improving the accuracy of clinical judgment.

Diagnostic reasoning in psychiatry is as intricate as it is risky (Elstein et al. 1978; Fitzhenry-Coor 1986; Fitzhenry-Coor and Nurcombe 1983; Gauron and Dickinson 1965; Sandifer et al. 1970; Kendell 1973; Nurcombe and Fitzhenry-Coor 1982). During the clinical encounter, the clinician elicits, notes, and verifies pertinent clinical cues. Early in the encounter, from an assembled but incomplete pattern of data, an array of diagnostic hypotheses is generated. Subsequently, in the light of evidence systematically gathered, each diagnostic possibility is progressively refined or deleted until the diagnostic conclusion is reached. The validity of the clinical endeavor, thus, depends upon the pertinence of the hypotheses generated, for it is upon them that deductive reasoning will hinge. It also depends upon the reliability of the history, signs, and investigations that constitute the evidence gathered for or against each of the hypotheses. The purpose of this paper is to propose systematic strategies based on principles of probability and empirical research, with the aim of sharpening clinical reasoning.

Goal-directed treatment planning and the principles of brief hospitalization.

Contemporary economic pressures to shorten hospitalization have produced serious confusion in child psychiatry, for no adequate rationale has been proposed to replace that appropriate to long-term inpatient care. In order to address this serious deficiency, the principle of hospital stabilization is introduced and discussed, along with the concept of goal-directed planning. The steps of goal-directed planning are presented. It is contended that the educational, communicative, medicolegal, and research advantages of goal-directed planning outweigh its disadvantages and that goal-direction should replace intuitive therapy-oriented planning and problem-orientation.

Minimizing adverse effects of low birthweight: four-year results of an early intervention program.

The outcome of an early intervention program for low-birthweight (LBW) infants was examined in this study. The intervention consisted of 11 sessions, beginning during the final week of hospitalization and extending into the home over a 3-month period. The program aimed to facilitate maternal adjustment to the care of a LBW infant, and, indirectly, to enhance the child's development. Neonates weighing less than 2,200 grams and under 37 weeks gestational age were randomly assigned to experimental or control conditions. A full-term, normal birthweight (NBW) group served as a second control. 6-month analyses of dyads who completed all assessments over a 4-year period (N's = 25 LBW experimental, 29 LBW control, and 28 NBW infant-mother dyads) showed that the experimental group mothers reported significantly greater self-confidence and satisfaction with mothering, as well as more favorable perception of infant temperament than LBW control group mothers. A progressive divergence between the LBW experimental and LBW control children on cognitive scores culminated in significant group differences on the McCarthy GCI at ages 36 and 48 months, when the LBW experimental group caught up to the NBW group. Possible explanations for the observed delay in the emergence of intervention effects on cognitive development and the mediating role of favorable mother-infant transactional patterns are discussed in light of recent evidence from the literature.

PIP: The outcome of an early intervention program for low-birthweight (LBW) infants was examined in this study. The intervention consisted of 11 sessions, beginning during the final week of hospitalization and extending into the home over a 3-month period. The program aimed to facilitate maternal adjustment to the care of a LBW infant, and indirectly, to enhance the child's development. Neonates weighing less than 2,200 grams and under 37 weeks gestational age were randomly assigned to experimental or control analysis of dyads who completed all assessments over a 4-year period (N's = 25 LBW experimental, 29 LBW control, and 28 NBW infant-mother dyads) showed that the experimental group mothers reported significantly greater self-confidence and satisfaction with mothering, as well as more favorable perception of infant temperament than LBW control group mothers. A progressive divergence between the LBW experimental and LBW control children on cognitive scores culminated in significant group differences on the McCarthy GCI at ages 36 and 48 months, when the LBW experimental group caught up to the NBW group. Possible explanations for the observed delay in the emergence of intervention effects on cognitive development and the mediating role of favorable mother-infant transactional patterns are discussed in light of recent evidence from the literature. These findings support a transactional model for facilitating mother-infant interactions. A logical next step would be to replicate the intervention program on a different sample of infants considered to be at biological risk. The studies were conducted at Medical Center Hospital in Vermont.

Diagnostic reasoning and treatment planning: II. Treatment.

The concepts of therapy-oriented and problem-oriented plans are discussed and their advantages and disadvantages considered. Goal-directed planning is proposed as an alternative to intuitive decision making. Goal-directed planning involves the abstraction of pivotal problems from a diagnostic formulation, the restatement of problems as goals, the selection of appropriate therapy, the designation of a target date, the stipulation of objectives, the selection of methods of evaluation and the monitoring of progress. Systematic goal-directed planning fosters teamwork, promotes accountability, obviates therapeutic drift and enhances outcome evaluation. Its chief disadvantage is its unfamiliarity.

Diagnostic reasoning and treatment planning: I. Diagnosis.

Information-processing research into the natural process of clinical reasoning is reviewed and the University of Vermont diagnostic reasoning research project is described. Experienced psychiatric diagnosticians use a hypothetico-deductive logic. The development of a profile of diagnostic competencies is outlined and a course in diagnostic reasoning for medical students, which specifically objectified the tactics and strategy of reasoning and resulted in a significant improvement in the profile of competencies, is described. Finally, the organisation of a diagnostic formulation is discussed.

Diagnostic reasoning and treatment planning: III. A case example.

A diagnostic formulation and treatment plan are derived from the case history of a psychiatrically disturbed adolescent admitted to hospital. This paper illustrates the goal-directed method of treatment planning outlined in the two previous papers.