Proposed changes to the psychiatric classification: towards DSM5.

OBJECTIVES: The World Health Organization and the American Psychiatric Association are revising their classifications of mental disorders--a costly, time-consuming exercise with wide implications. This article seeks to make practitioners aware of the proposed changes, which have been posted on the internet and are freely available. CONCLUSIONS: Taxonomic changes create strong emotions; the ones proposed for DSM5, though far from drastic, are no exception. The main diagnostic categories remain largely the same as in DSM-IV. Most of the modifications entail moving specific disorders from one section to another, deleting disorders that have had little practical use, or changing the name. The substance-related disorders and personality disorders sections have been changed the most. It remains to be seen whether the proposed new categories--several of them controversial--will make it to the final version.

Publishing ethics in child and adolescent psychiatry: essentials for authors and readers.

The ethics of publishing has received negligible attention in the child and adolescent psychiatry literature. We examine a range of ethical problems, including conflict of interest, bias, publishing fraudulent or inhumane research, redundant publication, plagiarism, concerns about authorship, insensitive use of language, and special issues about publishing research involving minors. Strategies to improve ethical standards of publishing are proposed.

Growing wealth and growing pains: child and adolescent psychiatry in Hong Kong, Malaysia and Singapore.

OBJECTIVE: Several Asian regions have undergone a dramatic transformation, some becoming very affluent. This paper aims to ascertain how countries that are becoming wealthy have dealt with child and adolescent mental health issues. METHOD: Population health status, child and adolescent mental health services, child psychiatry training, the number of child psychiatrists and related matters were examined in Hong Kong, Malaysia and Singapore. RESULTS: Hong Kong, Malaysia and Singapore are ethnically, religiously, socially and politically very different. In spite of considerable wealth and a growing recognition that mental health problems in the young are increasing, they face similar problems--lack of access to treatment due to a dearth of services and a lack of child psychiatrists (2.5, 0.5 and 2.8 per million people, respectively). CONCLUSIONS: Because the number of child psychiatrists is so small, their ability to provide services, advocate, train, maintain a professional identity, and deal with future crises is very limited. Other rapidly developing countries can learn from this experience and should take action early to prevent a similar outcome.

Side effects of second-generation antipsychotics: the experiences, views and monitoring practices of Australian child psychiatrists.

OBJECTIVE: The aim of this study was to ascertain the experiences, views and monitoring practices of Australian child psychiatrists regarding the metabolic and other side effects of second-generation antipsychotics (SGAs). METHOD: A 19-item questionnaire was posted to all members of the RANZCP Faculty of Child and Adolescent Psychiatry living in Australia. RESULTS: Of the 290 eligible members of the Faculty of Child and Adolescent Psychiatry, 126 (43%) returned a useable survey. SGAs are commonly prescribed for a range of disorders. The majority of respondents expressed a high level of concern regarding weight gain and other metabolic side effects. Weight gain was the most frequently observed and monitored side effect in clinical practice. Other side effects were observed and monitored to a variable extent. Notably, monitoring practices did not parallel psychiatrists' reported level of concern or knowledge regarding weight gain and metabolic side effects,nor coincide with published recommendations. CONCLUSIONS: Further research is required into the use, efficacy, side effects and monitoring of SGAs in children and adolescents, and there is a need to ensure that monitoring guidelines are implemented in clinical practice. This need is heightened by the likelihood that our data on clinicians' practice, which is based on their perceptions, may overestimate what actually occurs.

Selective serotonin reuptake inhibitors and suicidality in juveniles: review of the evidence and implications for clinical practice.

This article reviews the existing evidence regarding whether selective serotonin reuptake inhibitors increase suicidal behaviors in children and examines the implications of the findings for clinical practice and research. When balanced against the fact that depression in the young is a serious, recurring condition that produces personal suffering and can lead to suicide, the overall weight of the evidence favors pharmacologic treatment over nontreatment in moderate to severe depression. Nevertheless, the need for careful clinical monitoring of suicidality and attention to behavioral activation, manic switching, and medication compliance or withdrawal are clearly warranted.

International dissemination of evidence-based practice, open access and the IACAPAP textbook of child and adolescent mental health.

Dramatic changes have occurred in both publishing and teaching in the last 20 years stemming from the digital and Internet revolutions. Such changes are likely to grow exponentially in the near future aided by the trend to open access publishing. This revolution has challenged traditional publishing and teaching methods that-largely but not exclusively due to cost-are particularly relevant to professionals in low and middle income countries. The digital medium and the Internet offer boundless opportunities for teaching and training to people in disadvantaged regions. This article describes the development of the IACAPAP eTextbook of child and adolescent mental health, its use, accessibility, and potential impact on the international dissemination of evidence-based practice.

Is the party over? Cannabis and juvenile psychiatric disorder: the past 10 years.

OBJECTIVE: To critically review cannabis research during the past 10 years in relation to rates of use, behavioral problems, and mental disorders in young people. METHOD: Studies published in English between 1994 and 2004 were identified through systematic searches of literature databases. The material was selectively reviewed focusing on child and adolescent data. RESULTS: In the 27 years between 1976 and 2002, approximately half of all 12th graders had been exposed to cannabis in the United States. There is growing evidence that early and regular marijuana use is associated with later increases in depression, suicidal behavior, and psychotic illness and may bring forward the onset of schizophrenia. Most of the recent data reject the view that marijuana is used to self-medicate psychotic or depressive symptoms. Research on treatment is very limited. CONCLUSIONS: Research on the mental health effects of cannabis has increased dramatically. Although doubts still remain about the role of cannabis in the causation of juvenile psychiatric disorder, the weight of the evidence points in the direction of early and regular cannabis use having substantial negative effects on psychosocial functioning and psychopathology.

Health-related quality of life of children and adolescents with mental disorders.

OBJECTIVE: To compare the health-related quality of life (HRQL) between children aged 6-17 years with one of three mental disorders (attention-deficit/hyperactivity disorder, major depressive disorder, or conduct disorder), a physical disorder, and those with none of these disorders. METHOD: Parent reports describing the HRQL, mental disorders, and physical disorders of a national sample of 3,597 children and adolescents in Australia, aged 6-17 years (response rate = 70%), were obtained by means of a structured diagnostic interview and questionnaires. RESULTS: After controlling for age, gender, and family structure, children with mental disorders were reported to have a significantly worse HRQL in several domains than children with no disorder. In many areas they were reported to have a worse HRQL than children with physical disorders. Parents also reported that the problems of children with mental disorders interfered significantly with the daily lives of children, parents, and families. CONCLUSIONS: The findings are consistent with previous studies which have reported that adults with mental disorders have substantial impairment in their HRQL. The findings suggest that children with a mental disorder require help in many areas of their lives. Achieving this will require an integrated approach to health care delivery rather than the current distinction between physical and mental health services.

Use of health and school-based services in Australia by young people with attention-deficit/hyperactivity disorder.

OBJECTIVE: To examine use of health (including psychiatric) and school-based services by children and adolescents who met symptom criteria for attention-deficit/hyperactivity disorder (ADHD), the factors associated with service use, and barriers to service access. METHOD: The relationship between parents' perceptions of children's need for professional help, the impact of children's problems on children and parents, and services used during the previous 6 months were examined in a national sample of 398 children and adolescents with ADHD symptoms aged 6 to 17 years (70% response rate). Information was obtained from parents who completed the Diagnostic Interview Schedule for Children Version IV and standard questionnaires. Data collection took place between February and May 1998. RESULTS: Only 28% of those with ADHD symptomatology had attended health or school-based services. Among these, 41% had attended both health and school-based services, 39% had attended only health services, and 20% had attended only school-based services. Sixty-nine percent of parents attending health services wanted additional help. Parental perceptions that children needed professional help, children's functional impairment, the impact of problems on parents, and comorbid depressive or conduct disorders had a significant and independent relationship with service use. CONCLUSIONS: A minority of children and adolescents with ADHD symptomatology receives professional help for their problems in Australia. Counseling is the most frequent help provided, with many parents wanting additional help beyond that already provided. Factors other than children's ADHD symptomatology have a significant relationship with service attendance. Practical issues, including the cost of services and waiting lists are the most common barriers cited by parents as hindering access to services.

In the long run, skills are as good as pills for attention deficit hyperactivity disorder.

The need for stimulant treatment must be assessed regularly.

Mentoring young researchers: can the Donald J Cohen Fellowships model be applicable and useful to Australasian psychiatry?

OBJECTIVES: To describe the experience with the Donald J Cohen Fellowship program of the International Association for Child and Adolescent Psychiatry and Allied Professions (IACAPAP) and examine whether this model may be applied by the RANZCP to attract and support young researchers in Australasia. METHODS: The program at the September 2006 IACAPAP conference included 50 young researchers, 16 mentors and 8 'host fellows', and consisted of exclusive poster sessions, daily small-group mentoring meetings, oral presentation of selected papers, and a summary and feedback session. RESULTS: Informal feedback from mentors, mentees and conference organisers was very positive. CONCLUSIONS: A proposal about funding, participants and activities is presented. This suggests that a mentoring model similar to the Donald J Cohen Fellowship program can be easily conducted in Australasia. Implementing a program of this type would give College Fellows, the Australian Medical Council, the Commonwealth Government and other relevant organizations a clear message that the RANZCP is seriously committed to fostering and supporting research.

Reading the signs: impact of signed versus written questionnaires on the prevalence of psychopathology among deaf adolescents.

OBJECTIVE: There are no empirically validated measures of psychopathology that can be easily understood by signing deaf children and little reliable data on the prevalence of psychiatric disturbance in this population. The aim was to meet this need by developing an Australian Sign Language (Auslan) version of a widely used measure (the Youth Self-Report; YSR) which could be administered in an interactive CD-ROM format, to assess its reliability, and to compare the prevalence of clinically significant psychopathology in deaf adolescents when using the Auslan questionnaire versus the standard written version. This would also allow examining the validity of written questionnaires in this population. METHOD: Twenty-nine male and 25 female adolescents with severe or profound hearing loss from public and private schools in the Australian States of Tasmania (n = 11) and New South Wales (n = 43) agreed to participate and completed the written and the interactive Auslan versions of the YSR. Parallel forms were completed by parents (Child Behaviour Checklist) and teachers (Teacher's Report Form). RESULTS: The Auslan version showed comparable reliability to that reported for the standard YSR: internal consistency (alpha) ranging from 0.77 to 0.97 and test-retest agreement (r) from 0.49 to 0.78. The interactive Auslan version yielded a prevalence of clinically significant emotional and behavioural problems in deaf adolescents of 42.6% compared with 21.4% when using the standard English version. Prevalence for the wider Australian adolescent population (18.9%) was similar to that obtained among deaf adolescents when using the standard YSR (21.4%). However, it was higher among deaf adolescents (42.6%) when using the Auslan version (OR = 3.2, 95% CI = 1.83-5.58). According to the Auslan version, the syndromes Withdrawn/Depressed (OR = 6.5, 95% CI = 2.96-14.25), Somatic Complaints (OR = 4.8, 95% CI = 2.53-9.22), Social Problems (OR = 8.3, 95% CI = 4.16-16.47) and Thought Problems (OR = 5.7, 95% CI = 2.50-12.80) were much more prevalent among deaf adolescents than in the wider adolescent population, while Attention Problems (OR = 1.1, 95% CI = 0.39-3.17) and Rule-Breaking Behaviour (OR = 1.5, 95% CI = 0.73-3.17) were not. CONCLUSIONS: An interactive Auslan version of the YSR is reliable, better accepted and yields higher rates of disturbance than the standard written questionnaire. Clinicians should be aware that using written instruments to assess psychopathology in deaf adolescents may produce invalid results or may underestimate the level of disturbance, particularly emotional problems.

Outcome of patients with unipolar, bipolar and psychotic disorders admitted to a specialist child and adolescent mental health service.

OBJECTIVES: To evaluate the outcome of adolescents with unipolar, bipolar and psychotic disorders admitted to a specialist child and adolescent mental health service in order to inform and enhance service delivery. METHODS: Young people treated over a 2 year period at the Rivendell Unit, Sydney, Australia, were identified. Information was gathered from the medical records, mailed questionnaires and follow-up telephone interviews. RESULTS: Of 114 patients eligible for inclusion in the study, outcome information was available for 85 (75%). After 3 years, there was improvement in mood and general level of functioning for all diagnostic groupings. Overall, suicidal thought, self-harm and suicide attempts were not significantly reduced at follow up and relapse rates were high. Patients with bipolar disorder seemed to have a better response to treatment than other diagnostic groups on general functioning, education and employment. CONCLUSIONS: The findings confirm the seriousness and adverse psychosocial consequences of psychotic, unipolar and bipolar mood disorders in this age group, highlighting the need for consistent and systematic follow up of young people after treatment.

Depression in the young, parental depression and parenting stress.

OBJECTIVE: To examine the relationship between depression in children and adolescents, parental depression and parenting stress. METHODS: Fifty-three depressed youths, 9-16 years, were matched for age and gender and compared with 53 non-depressed controls. Depression was diagnosed using the Diagnostic Interview for Children and Adolescents-Revised (DICA-R). Parents completed questionnaires on depression and parenting stress. RESULTS: Parents of depressed children reported higher parenting stress and were more likely to perceive their children as 'difficult'. Univariate analysis demonstrated a relationship between children's depression and maternal depression but not with paternal depression. This became non-significant with multivariate analysis, implying that maternal depressive symptoms may have been due to caring for a depressed, thus 'difficult' child. CONCLUSIONS: Depressed youth were more likely to be perceived by mothers as 'difficult' and caused them significant parenting stress. The same phenomenon did not occur among the fathers. Clinicians need to consider the presence of depression among 'difficult' children and look for early depression in mothers of depressed youth.

Depressed youth, suicidality and antidepressants.

No cause for panic, but an incentive to improve clinical practice.

The validity of the DSM-IV subtypes of attention-deficit/hyperactivity disorder.

OBJECTIVE: To examine the validity of the three subtypes of ADHD defined by DSM-IV. METHOD: Studies published in English were identified through searches of literature databases. RESULTS: Estimates of the prevalence of ADHD have increased as a result of the introduction of DSM-IV criteria. Factor analytical and genetic studies provide some support for the validity of the distinction between the three subtypes. However, diagnosis of the combined subtype seems more reliable than the other two subtypes, although reliability is largely unknown for the latter. The hyperactive-impulsive subtype, the least common, differs from the other two subtypes in age distribution, association with other factors and neuropsychological parameters. Almost all treatment trials are based on participants with the combined type. CONCLUSION: Data supporting the validity of the inattentive and hyperactive-impulsive subtypes of ADHD a decade after the publication of DSM-IV are still scarce. Given that inattention is the hypothesized core ADHD symptom, it remains to be demonstrated that hyperactive-impulsive children who are not inattentive have the same condition. One of the main research deficits refers to data on treatment of the inattentive and hyperactive-impulsive subtypes.

Similarities and differences between aggressive and delinquent children and adolescents in a national sample.

OBJECTIVE: To examine differences in the correlates, comorbidity and use of services between aggressive and delinquent children and adolescents. METHOD: An Australian representative sample (n = 4083) of parents of children and adolescents were administered a psychiatric diagnostic interview, the Child Behaviour Checklist, and other instruments to measure service use. The characteristics of children with high scores (top 5%) in the aggressive and delinquent syndromes or both were then examined. RESULTS: The proportion of aggressive children decreased with increasing age while that of delinquents increased. The aggressive group was specifically associated with the impulsive-hyperactive subtype of attention deficit hyperactivity disorder (ADHD) (OR = 12.63; 95% CI = 5.97-26.74). Comorbidity between ADHD, aggression and delinquency was less frequent among adolescents than in children, with the exception of the inattentive subtype in which comorbidity was higher. Both aggressive and delinquent groups had a considerable overlap with conduct disorder. Aggressive and delinquent youths used services more often, but parents perceived aggressive children as more in need of help than delinquent ones. Living in a sole parent family was specifically associated with the delinquent group (OR = 3.34; 95% CI = 2.25-4.96). CONCLUSIONS: The results suggest that these empirically derived syndromes while sharing many features also differ in important ways, highlighting the need for further convergence between categorical and dimensional classifications. Their differential association with the subtypes of ADHD requires further examination and may help to understand the relationship between ADHD and conduct problems. The importance of aggressive behaviour in children should not be underestimated since it is associated with significant psychopathology, parental distress and use of services.