Towards a definition of multiple and complex needs in children and youth: Delphi study in Flanders and international survey.

BACKGROUND: Multiple and complex needs (MCN) in children and youth jeopardize their development and pose significant challenges to the different professionals they meet. However, there is no agreed-upon definition of this vulnerable population. OBJECTIVES: To develop a definition of 'MCN in children and youth' that is meaningful for all professionals involved in care delivery for this population. METHOD: A cross-sector, multidisciplinary, and geographically spread panel of 47 experts representing mental health, youth care, juvenile justice, and education in Flanders participated in an online Delphi study. Qualitative analysis of answers in the first round yielded four definition possibilities that participants then ranked in the second round. In the last round, participants rated their agreement with the highest ranked definition. An additional survey asked 25 international experts to rate and comment their agreement with the final definition. RESULTS: The final definition was: Children and adolescents with profound and interacting needs in the context of issues on several life domains (family context, functioning and integration in society) as well as psychiatric problems. The extent of their needs exceeds the capacity (expertise and resources) of existing services and sequential interventions lead to discontinuous care delivery. As such, existing services do not adequately meet the needs of these youths and their families. Cross-sector, integrated and assertive care delivery is necessary for safeguarding the wellbeing, development and societal integration of these young people. Response rates to the three Delphi rounds were 76.6, 89.1, and 91.3%. The definition was widely endorsed among Flemish (93.2% agreement) and international experts (88% agreement). CONCLUSION: A definition of MCN in children and youth was constructed using the Delphi method and further evaluated for international relevance in an additional survey. Such an agreed-upon definition can be valuable for optimizing care delivery and conducting research.

Professionals' views on the development process of a structural collaboration between child and adolescent psychiatry and child welfare: an exploration through the lens of the life cycle model.

This study, as a part of a participatory action research project, reports the development process of an innovative collaboration between child and adolescent psychiatry and child welfare, for adolescent girls with multiple and complex needs. The findings emerge from a qualitative descriptive analysis of four focus groups with 30 professionals closely involved in this project, and describe the evolution of the collaborative efforts and outcomes through time. Participants describe large investments and negative consequences of rapid organizational change in the beginning of the collaboration project, while benefits of the intensive collaboration only appeared later. A shared person-centred vision and enhanced professionals' confidence were pointed out as important contributors in the evolution of the collaboration. Findings were compared to the literature and showed significant analogy with the life cycle model for shared service centres that describe the maturation of collaborations from a management perspective. These findings enrich the knowledge about the development process of collaboration in health and social care. In increasingly collaborative services, child and adolescent psychiatrists and policy makers should be aware that gains from a collaboration will possibly only be achieved in the longer term, and benefit from knowing which factors have an influence on the evolution of a collaboration project.

Effect of Pycnogenol® on attention-deficit hyperactivity disorder (ADHD): study protocol for a randomised controlled trial.

BACKGROUND: Methylphenidate (MPH), the first choice medication for attention-deficit hyperactivity disorder (ADHD), is associated with serious adverse effects like arrhythmia. Evidence on the association of ADHD with immune and oxidant-antioxidant imbalances offers potential for antioxidant and/or immunomodulatory nutritional supplements as ADHD therapy. One small randomised trial in ADHD suggests, despite various limitations, therapeutic benefit from Pycnogenol®, a herbal, polyphenol-rich extract. METHODS: This phase III trial is a 10-week, randomised, double-blind, placebo and active treatment controlled multicentre trial with three parallel treatment arms to compare the effect of Pycnogenol® to MPH and placebo on the behaviour of 144 paediatric ADHD and attention-deficit disorder (ADD) patients. Evaluations of behaviour (measured by the ADHD-Rating Scale (primary endpoint) and the Social-emotional Questionnaire (SEQ)), immunity (plasma cytokine and antibody levels, white blood cell counts and faecal microbial composition), oxidative stress (erythrocyte glutathione, plasma lipid-soluble vitamins and malondialdehyde and urinary 8-OHdG levels, as well as antioxidant enzyme activity and gene expression), serum zinc and neuropeptide Y level, urinary catecholamines and physical complaints (Physical Complaints Questionnaire) will be performed in week 10 and compared to baseline. Acceptability evaluations will be based on adherence, dropouts and reports of adverse events. Dietary habits will be taken into account. DISCUSSION: This trial takes into account comorbid behavioural and physical symptoms, as well as a broad range of innovative immune and oxidative biomarkers, expected to provide fundamental knowledge on ADHD aetiology and therapy. Research on microbiota in ADHD is novel. Moreover, the active control arm is rather unseen in research on nutritional supplements, but of great importance, as patients and parents are often concerned with the side effects of MPH. TRIAL REGISTRATION: Clinicaltrials.gov number: NCT02700685 . Registered on 18 January 2016. EudraCT 2016-000215-32 . Registered on 4 October 2016.

Motor impairment among different psychiatric disorders: Can patterns be identified?

The aim of this study was to explore motor impairment in male adolescents suffering from psychiatric conditions. Taking into account the heterogeneity of a clinical population, motor profiles of distinctive diagnostic groups were evaluated. Whether or not motor ability discriminates between several diagnostic categories was investigated. The Bruininks-Oseretsky Test of Motor Proficiency, Second Edition (BOT-2) was administered to examine a detailed motor profile. The motor abilities of a clinical population (n=144) were compared to those of typically developing peers (n=87), using independent t-tests. To account for differences in intellectual functioning, a one-way ANCOVA was performed. To investigate the extent to which a specific diagnosis contributes to variation in motor scores a stepwise linear regression approach was applied. Results indicated that the clinical group performed significantly worse in comparison to the control group on all BOT-2 scales, even after controlling for IQ. The constructed models indicated that diagnostic categories accounted for a significant amount of the variance in motor ability scores. The results imply that motor ability of adolescents with a psychiatric disorder is in need of attention, regardless of the diagnosis and support the notion that objective motor assessment should be part of routine clinical practice.

Motor abilities of children and adolescents with a psychiatric condition: A systematic literature review.

AIM: To summarize research regarding the motor abilities of children and adolescents who suffer from a common psychiatric condition. METHODS: In order to outline the current knowledge regarding the motor abilities of children and adolescents with autism spectrum disorders (ASD), attention deficit hyperactivity disorder (ADHD), disruptive behavior disorders (DBD) and depression, a comprehensive systematic literature search was carried out using PubMed, Medline and ERIC databases. The databases were searched for relevant English language articles published between January 1990 and April 2014. Only studies that conducted a quantitative evaluation of motor ability and concerned individuals aged 0-18 years were included. A separate search was conducted for each disorder (ASD, ADHD, DBD, depression) in conjunction with each of the following keywords: (psycho/perceptuo) motor/movement skill(s), (psycho/perceptuo) motor/movement abilities, (psycho/perceptuo) motor/movement impairment, (psycho/perceptuo) motor/movement problem(s), motor function, motor coordination, motor performance, motor deficit(s). To detect supplementary relevant literature, the reference lists of the retrieved articles were examined. RESULTS: The search strategy yielded 51 studies meeting the inclusion criteria. In total, 28 studies were included that examined the motor abilities of children and adolescents with ASD. All studies indicated that they performed below average on various standardized motor assessment instruments. The overall prevalence rate for impairment in motor abilities ranged from 33% to 100%. Twenty-seven studies examined the motor abilities of children and adolescents with ADHD. Depending on the type of motor assessment tool and the cut-off points used by different researchers, prevalence rates of impairment in motor abilities are highly variable and ranged from 8% to 73%. Remarkably, there is a paucity of research addressing the motor abilities of individuals with DBD or depression. Furthermore, methodological problems, such as measurement and comorbidity issues, complicate the generalization of the findings. CONCLUSION: Research suggests that motor impairment is highly prevalent in some psychiatric conditions, particularly ASD and ADHD. However, future work is necessary to draw sound conclusions.

Motor abilities of adolescents with a disruptive behavior disorder: The role of comorbidity with ADHD.

The aim of this study was to explore the incidence, type and severity of motor impairment in male adolescents with a disruptive behavior disorder (DBD) and evaluate the role of comorbid ADHD. The Bruininks-Oseretsky test of motor proficiency, Second Edition was administered to examine a detailed motor profile and to compare the motor abilities of individuals with DBD (n = 99) to those of controls (n = 87). Additional subgroup analyses were conducted within the clinical population and encompassed (1) analyzing differences in motor profiles between individuals diagnosed with oppositional defiant disorder (ODD) or conduct disorder (CD) and (2) comparing the motor profiles of individuals with or without comorbid ADHD. The results indicated that individuals with a DBD showed a mixed motor impairment profile. Even after controlling for IQ, the DBD group obtained significantly lower scores in comparison to controls. The ODD and CD subgroups showed a similar motor profile. Presence of comorbid ADHD did not produce major differences in the motor profile. As approximately 79% of the adolescents with a DBD suffered from motor impairment, motor ability needs to be adequately addressed in research as well as in clinical practice.

Research projects in the collaborative antwerp psychiatric research institute.

INTRODUCTION: In the following article CAPRI presents its current research projects. SUBJECTS AND METHOD: The team leaders were asked to present and summarize the project they had been working on. The fields in which research was conducted are: Child and Adolescent Psychiatry, Cognitive and Psychomotor Dysfunctions in Schizophrenia, fMRI in Schizophrenia, Cognitive and Psychomotor Dysfunctions in Major Depressive Disorder, Chronic Fatigue Syndrome, Addiction Medicine and Forensic Psychiatry. RESULTS: An overview of recent and ongoing research projects is provided and the main results are summarized.

Serum testosterone concentration in male autistic youngsters.

OBJECTIVE: Research on the biological pathophysiology of autism has found some evidence that alterations in androgenic hormones may play a role in the pathophysiology of that disorder. We studied morning concentrations of serum testosterone in a very homogenic group of postpubertal youngsters with autism and a group of normal controls. METHODS: This study examines the serum testosterone concentration on 9 consecutive time points between 08.00 AM and 12.00 AM in 18 high- functioning male youngsters with autism (age 12-18) and 22 healthy volunteers participated in this study. All subjects passed the onset of puberty (Tanner-stage III-IV) and were of the Caucasian race. RESULTS: Repeated measures ANOVA revealed a significant time effect, with a decline in the testosterone concentration during the test and time X diagnosis interaction.The total testosterone concentration was significantly lower in the autism group compared to the group of normal controls. CONCLUSIONS: The significant decrease in serum testosterone concentration in male youngsters with autism suggest that the turnover of testosterone may take part in the pathophysiology of autism. Suggestions for further research are discussed.

Associations between common arginine vasopressin 1b receptor and glucocorticoid receptor gene variants and HPA axis responses to psychosocial stress in a child psychiatric population.

On the one hand, a suitable response to daily stressors is crucial for adequate functioning in any natural environment. On the other hand, depending on the individual's genetic makeup, prolonged stress that is accompanied by an inappropriate level of responsiveness may lead to physiological and psychiatric disorders. Several psychiatric conditions have been linked with stress and alterations in hypothalamic-pituitary-adrenal (HPA) activity. While stress is a general phenomenon, illness is only seen in a proportion of individuals, suggesting that genetic factors may play a role in the ability to cope with stress. In children, relatively little research has been conducted to determine the impact of genetic factors on the variability in HPA axis functioning. In the present exploratory investigation, 106 prepubertal children were studied to estimate the impact of four glucocorticoid receptor gene (NR3C1) polymorphisms (NR3C1-1 [rs10482605], ER22/23EK [rs6190], N363S [rs6195], N766N [rs6196]) and five arginine vasopressin (AVP) receptor 1b gene (AVPR1b) polymorphisms (AVPR1b_s1 [rs28536160], AVPR1b_s2 [rs28373064], AVPR1b_s3 [rs33976516], AVPR1b_s4 [rs33985287], AVPR1b_s5 [rs33933482]) on cortisol responses after a psychosocial stress test (public speaking task). ER22/23EK carriers had significantly lower cortisol responses to psychosocial stress compared with noncarriers. These findings provide evidence for the relevance of the ER22/23EK polymorphism in childhood HPA axis regulation. However, the small number of ER22/23EK subjects does not allow us to draw definitive conclusions about the genotypic effect.

Differences in hypothalamic-pituitary-adrenal axis functioning among children with ADHD predominantly inattentive and combined types.

Some evidence suggests that the HPA axis may be dysfunctional in children with attention-deficit/hyperactivity disorder (ADHD). The aim of this study was to investigate whether a different pattern of HPA axis activity is found between the inattentive (I) and combined (C) subtypes of ADHD, in comparison with healthy control children. A total of 100 prepubertal subjects [52 children with ADHD combined type (ADHD-C), 23 children with ADHD predominantly inattentive type (ADHD-I), and 25 healthy control subjects] were studied. The effects of stress were studied by comparing cortisol responses to a psychosocial stressor, consisting of a public speaking task. Children with ADHD-I showed an elevated cortisol response to the psychosocial stressor, in contrast to children with ADHD-C who showed a blunted cortisol response to the psychosocial stressor. When a distinction was made between responders and non-responders (a subject was classified as a responder when there was an increase in cortisol reactivity), hyperactivity symptoms were clearly related to a lower cortisol reactivity to stress. The results indicate that a low-cortisol responsivity to stress may be a neurobiological marker for children with ADHD-C, but not for those with ADHD-I. Directions for future research and clinical implications are discussed.

Hypothalamic-pituitary-adrenal reactivity in prepubertal children with social phobia.

BACKGROUND: The aim of this study was to investigate whether a different pattern of HPA axis activity is found between children with social phobia (SP) and healthy control children. METHODS: A total of 50 prepubertal subjects (25 children with SP and 25 healthy control subjects) were studied. The effects of stress were studied by comparing cortisol responses to a psychosocial stressor, consisting of a public speaking task. RESULTS: Children with SP showed an elevated cortisol response to the psychosocial stressor as compared with healthy controls. Trait but not state anxiety levels are associated with higher HPA axis activity. LIMITATIONS: Limited sample size. CONCLUSIONS: The results indicate that a higher cortisol responsivity to stress may be a neurobiological marker for prepubertal children with SP. Directions for future research and clinical implications are discussed.

Glucocorticoid receptor gene-based SNP analysis in patients with recurrent major depression.

Dysregulation of the hypothalamic-pituitary-adrenal axis, one of the stress-response systems, is one of the key neurobiological features of major depression (MDD). Data supporting the notion that glucocorticoid-mediated feedback inhibition is impaired in MDD come from a multitude of studies demonstrating nonsuppression of cortisol secretion following administration of the synthetic glucocorticoid dexamethasone. We examined whether genetic variations in the glucocorticoid receptor gene (Nuclear Receptor Subfamily 3, Group C, Member 1; NR3C1) could be associated with increased susceptibility for MDD using a whole gene-based association analysis of single nucleotide polymorphisms (SNPs). Four SNPs were identified in NR3C1 and genotyped in two well-diagnosed samples of patients with MDD ascertained in Belgium and northern Sweden, and matched control samples. In total, 314 MDD patients and 354 control individuals were included in the study. In the Belgian sample, we observed significant allele (p=0.02) and genotype (p=0.02) association with an SNP in the promoter region (NR3C1-1); in the Swedish sample, we observed significant allele (p=0.02) and genotype (p=0.02) association with the R23K SNP. The haplotype association studies showed modest evidence for an involvement of the 5' region of the NR3C1 gene in the genetic vulnerability for MDD. This study suggests that polymorphisms in the 5' region of the NR3C1 gene may play a role in the genetic vulnerability for MDD.

The genetics of panic disorder: state of the art.

Panic disorder (PD) is a highly prevalent, debilitating disorder. The heritability of the disease has been estimated by twin studies to be between 30 and 60%. The vulnerability for PD overlaps with an increased risk of bipolar disorder in some families. Classical genetic methods such as linkage analysis and association studies have not yet identified genetic risk factors beyond doubt. However, two independent studies confirm linkage of a specific syndrome characterized by PD, bladder problems, severe headaches, mitral valve prolapse and thyroid dysfunction to genetic markers on chromosome 13q. Association studies, although showing divergent results, give some support to a causative role for the genes encoding for monoamine oxidase A (MAO-A), cholecystokinin (CCK) and catechol-O-methyltransferase (COMT). Finally, a somatic duplication of a 19-Mb region on chromosome 15 has been associated with PD, but this intriguing finding awaits confirmation.

Activation of the inflammatory response system: A new look at the etiopathogenesis of major depression.

Major depression is accompanied by various direct and indirect indicators of a moderate activation of the inflammatory response system (IRS). Increased production of proinflammatory cytokines, such as interleukin-1 (IL-1), IL-6 and interferon (IFNgamma), may play a crucial role in the immune and acute phase response in depression. Lower serum zinc and changes in the erythron are indirect indicators of IRS activation in depression. The reciprocal relationships between IRS activation and hypothalamic-pituitary-adrenal (HPA)-axis hyperactivity, alterations in HP thyroid (HPT)-axis function and the availability of tryptophan to the brain led us to hypothesize that these neuroendocrine changes in depression are indicators of IRS activation and that a combined dysregulation of the IRS, the turnover of serotonin (5-HT) and the HPA-axis is an integral component of depression. The IRS activation model of depression provides an explanation for the psycho-social (external stress) as well as organic (internal stress) etiology of major depression. Antidepressive treatments with various antidepressive agents, including SSRIs, tricyclic and heterocyclic antidepressants, have in vivo and in vitro negative immunoregulatory effects, suggesting that their antidepressant efficacy may be attributed, in part, to their immune effects.