The role of a cinema seminar in psychiatric education.

As the goals of psychiatric education are evaluated and innovative teaching methods are sought, the current cinema represents an untapped resource. Thoughtful viewing of contemporary films with serious discussion of them in a film discussion group as part of the residency training program is a useful and enjoyable teaching format that helps bridge the gap between the art and science of psychiatry.

Somatoform disorders in children and adolescents: a review of the past 10 years.

OBJECTIVE: To review the literature on somatoform disorders in children and adolescents relevant to recertification by the American Board of Psychiatry and Neurology. METHOD: The psychiatric, pediatric, and psychological literatures were searched for clinical or research articles in the past 10 years dealing with somatization and somatoform disorders. RESULTS: Somatizing presentations are organized conceptually; somatization disorder, body dysmorphic disorder, hypochondriasis, conversion disorder, vocal cord dysfunction, pain disorder, and recurrent abdominal pain are described in children and adolescents; empirical evidence for treatment efficacy is scant, but clinically reasonable approaches are applied. CONCLUSION: More developmentally appropriate diagnostic schemas and better outcome studies are needed in all the somatoform disorders for children and adolescents.

The correlates of planning in adolescent suicide attempts.

Adolescent suicide attempts are often impulsive. It has been suggested that individuals who make nonimpulsive (premeditated) attempts have greater suicidal intent and are more hopeless than the impulsive attempters. Eighty-six adolescent suicide attempters were categorized according to the degree of premeditation of their attempt, as measured by two items of the Suicide Intent Scale. Sex, age, method of attempt, and the number of prior attempts were not useful discriminators between these groups. The nonimpulsive attempters were significantly more depressed and more hopeless than the impulsive attempters, as measured by several standardized scales. Measures of depression, hopelessness, and suicidal ideation were highly correlated in both groups. Anger turned inward and hopelessness were strongly correlated only in the premeditated group, suggesting that the nonimpulsive attempter's distress may bear a strong relationship to self anger.

Plasma levels and efficacy of imipramine treatment for enuresis.

OBJECTIVE: To determine the relationship between serum drug level and treatment efficacy in enuretic children treated with imipramine (IMI). METHOD: Eighteen children with primary nocturnal enuresis recruited from an ambulatory enuresis clinic population were the subjects of the study. After a baseline period of 2 weeks, children received placebo for 1 week followed by treatment with IMI in increasing dosages (1.0 mg/kg, 1.5 mg/kg, 2.0 mg/kg, and 2.5 mg/kg), each dosage being given for 2 weeks. Steady state IMI and desipramine levels were determined in each child for each dosage. Medication response ([drug % dryness-placebo % dryness] divided by [100%-placebo % dryness]) was determined for each dosing interval. RESULTS: Average dryness increased from 27.8% on placebo to 73% with 2.5 mg/kg of IMI. The overall correlation between medication response and combined serum level was .26 (p < .05). Side effects were monitored throughout the study and were found to be rare. CONCLUSIONS: The efficacy of IMI over placebo in reducing the frequency of nocturnal enuresis in children was confirmed. Efficacy was moderately but significantly related to increasing mg/kg dose. A higher serum level tended to be associated with a better response, but there was at least 700% variation in serum level between subjects at every dosage. Monitoring serum levels of imipramine in children with idiopathic functional nocturnal enuresis treated with that medication has a limited but real usefulness in clinical management.

Symptom perception in pediatric asthma: relationship to functional morbidity and psychological factors.

OBJECTIVE: Perception of changes in respiratory symptoms is a critical element in the self-management of pediatric asthma. The purpose of this study was to quantify perceptual accuracy in childhood asthma, to investigate links between symptom perception and functional morbidity, and to examine relationships between psychological variables and perceptual accuracy. METHOD: Eighty-six children, aged 8 to 15 years, attending an asthma camp made subjective estimates of asthma severity immediately prior to spirometry an average of 31 times at camp. The correlation coefficient between these measures (the child's accuracy index) was analyzed in relation to morbidity data and to scores on instruments that assessed trait anxiety, repressive coping style, intelligence, behavior problems, and parental symptom-reporting patterns. RESULTS: A wide range of perceptual ability was found, as children's subjective-objective r ranged from-.39 to .88. Greater perceptual accuracy was significantly related to fewer days missed from school and fewer emergency medical visits. Of the psychological variables assessed, only intelligence was significantly related to accuracy. CONCLUSIONS: Symptom perceptual ability is an important psychosomatic factor affecting the course of asthma for some children. Further study is indicated to understand psychological variables in addition to intelligence that may determine a child's perceptual accuracy.

Enuresis and encopresis.

Enuresis and encopresis must be seen as symptoms, not diseases, occurring in heterogeneous groups of children. A number of known factors are etiologically relevant to each symptom, and it is likely that others remain to be discovered. Both enuresis and encopresis are truly psychosomatic entities, in which psychosocial and physiologic elements act and react with one another in the development and maintenance of the problem. Further research, emphasizing concurrent psychological and biologic evaluation, is needed to answer the many still remaining questions about the etiology, natural course, and treatment of these common childhood symptoms. Psychiatrists should be available as consultants to colleagues in primary care during the evaluation of enuretic and encopretic children and should be ready to treat a subgroup of symptomatic children who have identifiable psychopathology.

Consultation-liaison training for child psychiatrists: results of a survey.

As a first step toward improving the quality of training for child psychiatrists in the increasingly important area of consultation-liaison work, a survey of current educational experiences in child psychiatry programs was carried out. Sixty-four programs (61% of those sampled) responded to a questionnaire and request for information. The consultation-liaison field remains minimally emphasized, as three-fourths of the programs devote less than 11% of the fellowship training time experiences to this area. Variations in the rotations are summarized, and five reasons for the low priority of consultation-liaison training are proposed.

Resistive-load detection in healthy school-aged children.

The ability to detect changes in respiratory resistance, which may be important in acute and chronic adaptations to airways obstruction, has not been measured previously in children. Two methods were used to measure the resistive-load detection thresholds (the added resistance that produced a "just noticeable difference" in perception) in a group of 38 healthy children and adolescents aged 7-16 years. Total respiratory system resistance (Rrs), as measured by forced oscillation, was used as an index of each child's intrinsic baseline (pre-test) resistance. To determine thresholds a computer program added various percentages of baseline resistance according to response (first method) and then in random order (second method). Thresholds by at least one of the two methods were detectable in 32 of the children (84%), and failure to detect a threshold was less common in older than in young children. Thresholds obtained by each method were significantly related to one another (r = 0.54, P < 0.05). Baseline resistance accounted for a marginally significant proportion of the variation in thresholds as assessed by the tracking method (R2 = 0.12, P < 0.10) and a large proportion of the variation in thresholds as assessed by the random method (R2 = 0.66, P < 0.0001). Thresholds expressed in terms of percent of baseline resistance were found to have mean values of 100.4-105.0%, regardless of gender or age. Results from a comparison group of adults (n = 10) indicated lower threshold by both procedures (mean values, 71.90-76.50%). We conclude that perceptual thresholds for added resistive loads are determined, in part, by growth-related changes in intrinsic resistance.

Spirometric patterns in childhood asthma: peak flow compared with other indices.

The objective of this study was to determine patterns of pulmonary function abnormalities and to evaluate how adequately peak flow monitoring was correlated to other spirometric indices in childhood asthma. Ninety-one children, aged 8-15 years, with moderate-to-severe asthma were repeatedly tested in a summer camp. On-site medical staff permitted 24-hour-a-day supervision. Subjective and objective clinical evaluations of asthma status were made over 14 consecutive days. Detailed clinical history and clinical observations were made by an experienced staff, and a total of 2,663 pulmonary function tests were performed regularly three times daily and whenever a child sensed asthma symptoms. Patterns of obstruction were divided into large airway abnormalities and small airway abnormalities. There was a low concordance between standard large airway measures, such as the peak expiratory flow rate (PEFR) or the forced expiratory volume in 1 second (the FEV1), and measures of small airway obstruction, such as the forced expiratory flow rate 25-75% (FEF25-75). Normal PEFR measurements do not always indicate that all other pulmonary function measures are normal. In fact, 18% of children with a normal PEFR had abnormal FEF25-75 values. Results demonstrated that the FEF25-75 was the most specific and sensitive measure of airway obstruction. PEFR is widely used to monitor asthma symptoms objectively because it is technically simple to perform, relatively inexpensive, and helpful in most cases. It is, therefore, appropriate for asthma education programs to recommend PEFR as an objective measure to guide in making therapeutic decisions. Our data and clinical observations support the "Guidelines for the Diagnosis and Management of Asthma" of the NIH Health Asthma Education Program that suggest that children have more complete pulmonary function testing along with frequent PEFR measures. Many children may appear asymptomatic, while recording normal PEFR measures, and still having significant asthma. Repeated pulmonary function testing and evaluation of the pattern of respiratory obstruction aids in managing this challenging group. We recommend that efforts be made to develop a simple and inexpensive method of measuring FEF25-75 that will allow this measurement to be made even at home.

Thresholds of resistive load detection in children with asthma.

Threshold detection of added resistive loads was studied in asthmatic children and compared to data previously obtained in a group of healthy children. The relationships between possible psychological predictors of perceptual ability, the perceptual threshold, and functional morbidity variables were also investigated. Our subjects were 103 children (mean age, 10.9 years) with asthma who completed two laboratory protocols in which they were asked to distinguish breaths with varying degrees of added resistance from unloaded breaths. Using two different computer-driven protocols, resistances were presented as percentages of each child's intrinsic respiratory system resistance (R(rs)). Cognitive ability was assessed through subtests of the Wechsler Intelligence Scale for Children, 3rd edition (WISC-III), and functional morbidity was quantified through a combination of school absences, emergency medical visits, and days hospitalized. Detection thresholds for both protocols were highly correlated with intrinsic resistance (r = 0.49 and 0.66; P < 0.001). Weber fraction thresholds were significantly lower for asthmatic children than healthy controls. Thresholds were not significantly related to either intelligence or pulmonary functional abnormalities due to asthma. Methodologic limitations require cautious interpretation of the results, but we conclude that psychophysical approaches may be useful in the study of symptom perception in pediatric asthma.

Repressive-defensive style and physiological reactivity among children and adolescents with asthma.

OBJECTIVE: This study evaluates the concordance of two self-report methods of operationalizing repressive-defensive style in children with asthma. It was hypothesized that, compared with low-anxious children, repressive-defensive children would exhibit increased physiological reactivity during a stressful laboratory task, despite comparable self-reports of state anxiety. METHODS: Ninety-one children and adolescents (mean age = 11.5 years) with asthma participated in the study. Repressive-defensiveness was operationalized as self-reported low distress coupled with high defensiveness or restraint. Self-report data reflecting trait anxiety, defensiveness, and personality style were used to classify children as repressive-defensive by two independent methods. Physiological reactivity was operationalized as standardized changes in peripheral temperature, heart rate, and/or skin conductance from baseline to a stressful task. For the stressful task, children spoke into a tape recorder about a stressful or embarrassing event. RESULTS: Each method classified 20% of children as repressive-defensive. However, of the children classified as repressive-defensive by either method (n = 26), only 38% (n = 10) were classified as repressive-defensive by both methods. In addition, regardless of the classification method, repressive-defensive children did not consistently differ from low-anxious children with respect to physiological reactivity under stress, one of the hallmarks of repressive-defensiveness in adults. CONCLUSION: These results cast doubt on our ability to measure repressive-defensiveness reliably using self-report measures. Future research should determine whether children and adolescents can be reliably classified as repressive-defensive, whether this classification is related to physiological reactivity as in adults, and whether repressive-defensiveness plays a role in emotionally triggered asthma symptoms.

Stress and airway resistance in children with asthma.

OBJECTIVE: The present study implements an experimental paradigm to examine airway reactivity to stress in children with asthma and controls. METHOD: 114 children with asthma and 30 controls (ages 9-15) participated. The protocol involved 5 min of baseline physiological measurements followed by a 5-min stressful task. Skin conductance (EDG), skin temperature, and heart rate were measured continuously. Airway resistance was measured at baseline and after the task. RESULTS: 110 children (76% of the sample) were significantly "stressed" as shown by physiological changes. Asthmatics and controls differed on overall airway resistance, F(1, 108)=12.3, P<.001. The entire sample demonstrated a trend toward increased airway resistance in response to stress, F(1,108)=3.1, P<. 08. A portion of asthmatics (22%) had increases of greater than 20% of baseline airway resistance. Changes in airway resistance in response to stress were unrelated to asthma severity, F(2,78)=2.0, ns. CONCLUSION: Children with asthma and controls demonstrate variation in airway function in response to stress, although increases are likely more meaningful for children with asthma. Further research is needed to examine the mechanisms underlying this response.

Functional versus organic knee pain in adolescents. A pilot study.

Psychologic factors, usually assessed with the Minnesota Multiphasic Personality Inventory, have been reported by various researchers as significant in certain groups of adult orthopaedic patients--most notably those with low back pain. Much less is known about children and adolescents or other orthopaedic complaints. We did a pilot study to determine how significant nonorganic factors are in adolescents presenting with knee pain and whether a brief screening protocol conducted in the waiting room can predict which adolescents do not have organic etiology for the knee pain. Twenty-eight consecutive adolescents were given the Junior-Senior High School Personality Questionnaire (HSPQ), and information on other variables was obtained prior to their first orthopaedic visit. Followup after six to eight months revealed that over a third of the patients had significant or predominant psychologic factors associated with the knee pain. The HSPQ and other individual variables were found, overall, to be of little help in differentiating between the functional and organic groups.

"The new morbidities," physician competence, and consumer utilization.

Results of a questionnaire assessing pediatricians' perceived competence regarding psychosocial, developmental and traditional medical problems were analyzed. The data were compared with a similar questionnaire distributed to seventh grade teachers, youth and parents assessing problems for which pediatricians were utilized. The results reveal that pediatricians rate their competency higher in the area of traditional medical problems. The implications of this study are discussed.

Accuracy of symptom perception in childhood asthma.

Children's reports of their asthma symptoms are used as important data in the assessment and management of pediatric asthma, but little is known about the accuracy of such reports. Children's subjective perception of the level of asthma symptoms was correlated with peak expiratory flow rate measures on average of 34 observations for 37 children with asthma. Subjective/objective correlations for a given child varied from 0.86 to -0.16. The children's perceptual accuracy was not related to age or sex, or to duration or severity of asthma. Implications for clinical practice are discussed.

The psychiatric consultant in professional team sports.

The role of the sport psychiatrist consulting to a professional sports team is complex, challenging, and varied. Sport psychiatrists enhance the psychosocial development of the athlete by removing obstacles to growth and by facilitating lines of communication that support exchange of information, sharing of feelings, and the development of solid winning relationships on the team and throughout the organization. The consultant psychiatrist often provides input both to players and to management, however; these dual responsibilities raise ethical concerns and often require the services of additional treating psychiatrists and other mental health professionals.

AIDS education in the schools: a literature review as a guide for curriculum planning.

As plans for massive public AIDS education grow, pediatricians will become increasingly involved with school systems as consultants and leaders. A review of relevant literature on students' current level of knowledge about AIDS and on educational efforts to date with high-risk groups (homosexuals and intravenous drug users) provides the rationale for school-based AIDS education. Literature describing the approaches used and the impact of programs for sex education, drug abuse prevention, and reduction of prejudice towards the disabled is reviewed to extrapolate that which applies to AIDS education. Important developmental characteristics of adolescents are discussed insofar as they have implications for the planning of AIDS curricula.

PIP: Although there is a lack of sufficient data for the rational development of school-based acquired immunodeficiency syndrome (AIDS) education programs, trial-and-error experience has suggested several guidelines. Children and adolescents appear to be becoming increasing knowledgeable about AIDS, but important gaps exists, especially about transmission. Work that has been done to date with high-risk groups (e.g., homosexual men) suggests that educational efforts can have a positive effect on reducing dangerous sexual and even drug use practices. This finding provides justification for larger school-based projects, particularly if the AIDS crisis can be made relevant to typical adolescent concerns. Unfortunately, the extensive literature on sex education contains discouraging expectations for behavior change in response to education. Broadly based interventions, in which the education is integrated into a variety of situations and repeated in multiple forms, are more likely to change sexual behavior than brief, encapsulated presentations. Experience with sex education also suggests that parental involvement with the AIDS curriculum may increase its effectiveness. Extrapolation from efforts at drug abuse prevention suggests that a direct emphasis on providing students with coping skills will be more effective than merely discussing or teaching about AIDS. Students can be helped to clarify their own attitudes toward sexuality, understand the decisions that flow from these beliefs, weigh the risks and benefits of their decisions, and learn ways to reduce the risk of AIDS if they choose to be sexually active. Since school children are likely to have to deal with a classmate who is positive for antibodies to the AIDS virus, altering prejudices and stigmas is another important goal. An understanding of the developmental psychology of childhood and adolescence should underlie all AIDS curricula.

Pediatric and psychiatric collaboration in the management of childhood asthma.

With many asthmatic children for whom emotional factors are significant, joint pediatric and psychiatric management is essential. A three-level model of collaboration is presented, including (1) pediatric care, (2) psychiatric consultation, and (3) inpatient psychosomatic treatment. The organization, professional roles, and treatment protocol of the psychosomatic inpatient service are described. A review of the first 16 asthmatic children who received inpatient care in the program suggests that such a model may present a viable alternative to long-term residential care.

Adolescent risk-takers: a trauma center study of suicide attempters and drivers.

Adolescence is a developmental stage characterized by excessive risk-taking behavior that produces adverse health effects, typically in the form of injury. At issue is whether adolescent suicide attempters and injured adolescent motor vehicle drivers constitute a common risk group and are differentiated by the response of the emergency medical care system and by case disposition. Data originated in the medical records of a Rhode Island (USA) trauma center. The two study groups were not distinguished by religious preference, socioeconomic status or timing of the injury incident, but differed significantly by gender, race, emergency vehicle use, hospital admission rates, and seasonal injury patterns. Alcohol and drug involvement was examined, but serious data deficiencies were noted.

The role of a directly observed, continuous case conference in the training of child psychiatrists.

The directly observed, continuous case conference is studied in depth as a format for teaching child psychotherapy. The effects of group dynamics, direct observation, and the specific case on the processes of therapy, learning, and supervision are examined. Six guidelines are set forth to maximize the effectiveness of the conference.