Child and adolescent mental health multiaxial classification: A useful biopsychosocial framework for paediatrics?

In child and adolescent psychiatry, the multiaxial classification approach has been developed over some decades and remains very relevant as it encapsulates the biopsychosocial approach, an approach which is also central to paediatric practice. There is considerable overlap between developmental-behavioural paediatrics and child and adolescent mental health, including presenting clinical problems, diagnoses, multidisciplinary and holistic approach to assessment and management, and similar use of pharmacological agents and psychosocial interventions. Multiaxial classification can be of use to paediatricians in a variety of ways, both in clinical practice and for teaching purposes. It can improve communication between the two disciplines and promotes a more holistic diagnostic representation in a structured and consistent format. Presented here are a number of practical ways in which the multiaxial biopsychosocial framework can be used, including case description, formulation, timeline and interventions, training and teaching.

Outcomes of standardised approach to metabolic bone disease of prematurity.

AIM: To assess the current protocol of metabolic bone disease (MBD) at three Monash Health neonatal units (Melbourne, Australia). METHODS: Retrospective audit of 171 infants born at <32 weeks' gestation over 18 months. Mean gestational age was 28.6 ± 2.1 weeks, and birthweight was 1190 ± 374 g. Risk factors of MBD include intra-uterine growth retardation (n = 33, 19.3%), maternal pre-eclampsia (n = 17, 9.9%), necrotising enterocolitis (n = 9, 5.4%) and medications like methylxanthines (94.2%; mean 54.8 days), diuretics (38.6%; mean 49.2 days) and glucocorticoids (5.3%; mean 35 days). RESULTS: In total, 84.8% infants had an initial MBD screen (mean age 36.3 days), with 45% having repeated monitoring (mean age 71.9 days), and 14.2% had initial alkaline phosphatase levels >500 U/L, decreasing to 10.1% on follow-up. All infants received additional vitamin D supplementation of 400 IU/day, phosphate of 25.1% (n = 43) and calcium of 19.9% (n = 34). Fractures were identified from clinical documentation in 2.9% (n = 5) of infants. Stratifying into phosphate-treated and untreated groups revealed significant differences (P < 0.001) for gestational age and birthweight: 26.7 ± 1.7 weeks/918 ± 272 g for treated versus 29.2 ± 1.9 weeks/1283 ± 359 g for untreated. In the phosphate-treated group, improvement was seen in mean alkaline phosphatase (pre-treatment 467 ± 204 U/L and post-treatment 342 ± 221 U/L, P < 0.01) and mean phosphate levels (1.8 ± 0.4 vs. 2.2 ± 1.0 mmol/L, P < 0.01). Linear growth difference between phosphate-treated (n = 10) and untreated groups (n = 24) was insignificant at >6 months of age (P = 0.13), although this may reflect limited data. CONCLUSION: Adequate first-line supplementation with vitamin D and phosphate appeared to improve biochemical markers of MBD, but given the observational nature of this study, further longitudinal/prospective studies are required to confirm these findings.

Seeing the world through others' minds: Inferring social context from behaviour.

Past research tells us that individuals can infer information about a target's emotional state and intentions from their facial expressions (Frith & Frith, 2012), a process known as mentalising. This extends to inferring the events that caused the facial reaction (e.g. Pillai, Sheppard, & Mitchell, 2012; Pillai et al., 2014), an ability known as retrodictive mindreading. Here, we enter new territory by investigating whether or not people (perceivers) can guess a target's social context by observing their response to stimuli. In Experiment 1, perceivers viewed targets' responses and were able to determine whether these targets were alone or observed by another person. In Experiment 2, another group of perceivers, without any knowledge of the social context or what the targets were watching, judged whether targets were hiding or exaggerating their facial expressions; and their judgments discriminated between conditions in which targets were observed and alone. Experiment 3 established that another group of perceivers' judgments of social context were associated with estimations of target expressivity to some degree. In Experiments 1 and 2, the eye movements of perceivers also varied between conditions in which targets were observed and alone. Perceivers were thus able to infer a target's social context from their visible response. The results demonstrate an ability to use other minds as a window onto a social context that could not be seen directly.

Hospitalisations for sickle-cell disease in an Australian paediatric population.

AIM: Sickle-cell disease (SCD) is more prevalent in Australia due to increased migration; however, the Australian paediatric SCD population has not been previously described. This study aimed to identify the demographic features of and quantify the hospital resource utilisation in the SCD population at The Royal Children's Hospital in Victoria. METHODS: This was a retrospective chart review of SCD patients who presented to the Royal Children's Hospital over a 10.5-year period. Descriptive analyses were conducted. RESULTS: Thirty-seven SCD patients aged from 0.2 to 18.0 years (mean: 8.5 ± 4.8 years) had 535 admissions over the 10.5-year period. The population was made up of 28 homozygous sickle-cell disease, 1 sickle C disease and 8 sickle-cell beta patients from a variety of ethnic backgrounds. Admissions included 264 unplanned admissions, that is 258 admissions via the emergency department and 6 admissions via outpatients, and 271 planned admissions. Mean length of stay for unplanned admissions was 3.2 ± 2.6 days. Common diagnoses for unplanned admissions were 187 vaso-occlusive crisis (70.8%), 32 infections (12.1%) and 26 anaemic episodes (9.8%). Transfusion therapy (91.9%) accounted for the majority of planned admissions. CONCLUSIONS: Children with sickle-cell disease in an Australian setting require hospitalisation for various reasons related to disease, either unexpected complications or elective procedures. Factors affecting the provision of optimal healthcare to be explored include the multicultural demographics of the SCD population, the timely management of vaso-occlusive crises and the availability of SCD-related protocols.