One-year outcome of manualised behavior therapy of chronic tic disorders in children and adolescents.

BACKGROUND: Chronic tic disorders are neurodevelopmental disorders that can be treated with Habit Reversal Training (HRT) and Exposure Response Prevention (ERP). Intermediate and long-term effects have been examined after individual treatment with HRT, whereas evaluation of long-term outcome after an initial treatment with ERP, or a combination of HRT and ERP is lacking. The present study examines the long-term effect after a combined treatment with HRT and ERP delivered in an individual or a group setting METHODS: Fifty-nine children and adolescents diagnosed with a chronic tic disorder were randomised to manualised treatment combining HRT and ERP as individual or group training. Forty-seven were re-examined 1 year after acute outcome. Outcome measures included Total Tic Severity score (TTS) measured by the Yale Global Tic Severity Scale (YGTSS) and Beliefs About Tics Scale (BATS) RESULTS: In a mixed model, it was shown that the initial improvement with both individual and group treatment was maintained throughout the follow-up period. There were no significant differences between the two methods of treatment delivery. Of all participants completing the 12 months evaluation, 74.4% were considered responders. There was a significant positive association between the reduction of TTS and the reduction in BATS. In a latent class post-treatment trajectory analysis, two classes were identified, where high baseline severity increased the likelihood of being in the lesser responder class. Similar, but only as a trend, having ADHD, planning difficulties or hypersensitivity increased the risk of a lesser response. CONCLUSIONS: The present study compares the efficacy in individualised and group treatment of providing manualised therapy for child and adolescent tic disorders using two behavioural methods (combined HRT and ERP) both of which have been shown to have acute benefits but only one of which has been validated for longer term effectiveness. In the present study, both individualised and group treatments showed benefit throughout a 1-year follow-up period with several potential confounds affecting outcomes, while the relative benefits of either HRT and ERP were not addressed. Trial registration NCT04594044, 1-10-72-216-15, registered 19th October 2020, retrospectively registered, https://register.clinicaltrials.gov/prs/app/template/Home.vm?uid=U0005BW2&ts=9&sid=S000ABEY&cx=-wlx7vb The study is approved by the National Ethical Committee (1-10-72-216-15) and the Danish Data Protection Agency (1-16-02-490-15), registered 12 October 2015.

The immediate effect of COVID-19 pandemic on children and adolescents with obsessive compulsive disorder.

BACKGROUND: Obsessive compulsive disorder (OCD) is a distressing psychiatric disorder. Traumas may trigger or aggravate OCD symptoms. COVID-19 pandemic has coursed a global crisis and has been associated with onset of psychiatric disorders in adults. Little is known about children/adolescents with OCD. The present study aimed to examine how children/adolescents with OCD react towards COVID-19 crisis. METHODS: A questionnaire was distributed to two separate groups of children/adolescents. One group was a clinical group newly diagnosed at a specialized OCD clinic. All the children/adolescents had a current close contact to a therapist or doctor. The other group was a survey group identified through the Danish OCD Association. Most of these children/adolescents were diagnosed years ago, and their primary treatment was completed. For the clinical group, data from patient files was available. RESULTS: In both groups, but most pronounced in the survey group, participants experienced a worsening of their OCD, anxiety, and depressive symptoms. The aggravation of OCD correlated with the worsening of anxiety, depressive symptoms, and the extent of avoidance behavior. For both groups, OCD aggressive symptoms predicted a significant worsening. Poor baseline insight showed a trend to predict a symptom worsening. The worsening was most pronounced in children with early age of onset and a family history of attention deficit hyperactivity disorder. CONCLUSIONS: To our knowledge, this is one of the first studies examining the effect of COVID-19 in children/adolescents with OCD. The effect was examined in two separate populations strengthening the findings. The study points towards an influence of the OCD phenotype, baseline insight suggesting a continued vulnerability, and a family history of psychiatric disorders. TRIAL REGISTRATION: The study is approved by the Danish Data Protection Agency (1-16-02-147-20) registered 1st of April 2020. Oral and written information was given to parents and patients and written consent from patients over 15 years and parents were received.

Predictors of therapeutic treatment outcome in adolescent chronic tic disorders.

BACKGROUND: Chronic tic disorders may have a major impact on a child's function. A significant effect has been shown for combined habit reversal training (HRT) and exposure response prevention (ERP) treatment delivered in an individual and group setting. AIMS: The present study examines predictors and moderators of treatment outcome after an acute therapeutic intervention. METHOD: Fifty-nine children and adolescents were randomised to manualised treatment combining HRT and ERP as individual or group training. Age, gender, baseline tic severity, Premonitory Urge for Tics Scale (PUTS) scores, Beliefs about Tic Scale (BATS) scores, hypersensitivity and comorbid psychiatric symptoms were analysed as predictors of outcome. The same characteristics were examined as moderators for individual versus group treatment. Outcome measures included the change in total tic severity (TTS) score and functional impairment score (as measured by the Yale Global Tic Severity Scale (YGTSS)). RESULTS: Internalising symptoms predicted a lesser decrease in functional impairment. The occurrence of obsessive-compulsive symptoms predicted a larger decrease in TTS. Baseline hypersensitivity and high scores on depressive symptoms favoured individual treatment. High baseline PUTS scores favoured group therapy. CONCLUSIONS: This is the first study examining factors predicting and moderating perceived functional impairment following a therapeutic intervention. The study adds to the knowledge on predictors and moderators of TTS. Furthermore, this is the first study examining the effect of the BATS score. The study points towards factors that may influence treatment outcome and that require consideration when choosing supplemental treatment. This applies to comorbid anxiety and depressive symptoms, and to the child's belief about their tics and premonitory urge. DECLARATION OF INTEREST: None.

Structure and clinical correlates of obsessive-compulsive symptoms in a large sample of children and adolescents: a factor analytic study across five nations.

The underlying structure of obsessive-compulsive disorder (OCD) remains to be confirmed in child and adolescent populations. In this paper we report the first factor analytic study of individual OCD items from Children's Yale-Brown Obsessive Compulsive Scale (CY-BOCS). OCD symptoms were assessed using the CY-BOCS symptom checklist in a sample of 854 patients with OCD (7-18 years of age) recruited from clinics in five countries. Pooled data were subjected to exploratory and confirmatory factor analysis (CFA) to identify the optimal factor structure. Various models were tested for age and gender subgroups. Also, the invariance of the solution across age and gender was tested and associations with demographic and clinical factors were explored. A three-factor model provided the best-fit solution. It consisted of the following factors: (1) harm/sexual, (2) symmetry/hoarding, (3) contamination/cleaning. The factor structure was invariant for age and gender across subgroups. Factor one was significantly correlated with anxiety, and factor two with depression and anxiety. Factor three was negatively correlated with tic disorder and attention-deficit/hyperactivity disorder (ADHD). Females had higher scores on factor two than males. The OCD symptom structure in children and adolescents is consistent across age and gender and similar to results from recent child and adolescents although hoarding may not be a separate factor. Our three-factor structure is almost identical to that seen in early studies on adults. Common mental disorders had specific patterns of associations with the different factors.

Early-adult outcome of child and adolescent mental disorders as evidenced by a national-based case register survey.

BACKGROUND: Mental disorders show varying degrees of continuity from childhood to adulthood. This study addresses the relationship of child and adolescent mental disorders to early adult psychiatric morbidity. METHODS: From a population at risk of 830,819 children and adolescents aged 6-16 years, we selected all those (n=6043) who were enrolled for the first time in the Danish Psychiatric Register with an ICD-10 F00-99 diagnosis in 1995-1997, and identified any mental disorder for which they received treatment up to 2009. RESULTS: Neurodevelopmental and conduct disorders were the principal diagnostic groups at 6-16 years and exhibited a characteristic male preponderance; while affective, eating, neurotic, stress-related and adjustment disorders were more common in girls. Over a mean follow-up period of 10.1 years, 1666 (27.6%) cases, mean age 23.4 years, were referred for treatment to mental health services, and they had a markedly higher risk than the general population (RR 5.1; 95% CI 4.9-5.4). Affective, eating, neurodevelopmental, obsessive-compulsive and psychotic disorders had the strongest continuity. Heterotypic transitions were observed for affective, eating, neurodevelopmental, personality and substance use disorders. CONCLUSIONS: These findings suggest that individuals with psychiatric antecedents in childhood and adolescence had a high risk of being referred for treatment in early adulthood, and many mental disorders for which they required treatment revealed both homotypic and heterotypic continuity.

The classification of Obsessive-Compulsive and Related Disorders in the ICD-11.

BACKGROUND: To present the rationale for the new Obsessive-Compulsive and Related Disorders (OCRD) grouping in the Mental and Behavioural Disorders chapter of the Eleventh Revision of the World Health Organization's International Classification of Diseases and Related Health Problems (ICD-11), including the conceptualization and essential features of disorders in this grouping. METHODS: Review of the recommendations of the ICD-11 Working Group on the Classification for OCRD. These sought to maximize clinical utility, global applicability, and scientific validity. RESULTS: The rationale for the grouping is based on common clinical features of included disorders including repetitive unwanted thoughts and associated behaviours, and is supported by emerging evidence from imaging, neurochemical, and genetic studies. The proposed grouping includes obsessive-compulsive disorder, body dysmorphic disorder, hypochondriasis, olfactory reference disorder, and hoarding disorder. Body-focused repetitive behaviour disorders, including trichotillomania and excoriation disorder are also included. Tourette disorder, a neurological disorder in ICD-11, and personality disorder with anankastic features, a personality disorder in ICD-11, are recommended for cross-referencing. LIMITATIONS: Alternative nosological conceptualizations have been described in the literature and have some merit and empirical basis. Further work is needed to determine whether the proposed ICD-11 OCRD grouping and diagnostic guidelines are mostly likely to achieve the goals of maximizing clinical utility and global applicability. CONCLUSION: It is anticipated that creation of an OCRD grouping will contribute to accurate identification and appropriate treatment of affected patients as well as research efforts aimed at improving our understanding of the prevalence, assessment, and management of its constituent disorders.

Association between Attention-Deficit Hyperactivity Disorder in childhood and schizophrenia later in adulthood.

PURPOSE: To estimate the risk of schizophrenia in adulthood among children and adolescents with ADHD compared to the background population. SUBJECTS/MATERIALS AND METHODS: Two hundred and eight youths with ADHD (183 boys; 25 girls) were followed prospectively. Diagnoses of schizophrenia were obtained from The Danish Psychiatric Central Register. The relative risk (RR) of schizophrenia for cases with ADHD, compared to the normal population, was calculated as risk ratios. Hazard ratios (HR's) by Cox regression were calculated in the predictor analyses. RESULTS: Mean age for ADHD cases at follow-up was 31.1years. Schizophrenia diagnoses were given to 3.8% of these cases. Compared to the general population, RR of schizophrenia in cases with ADHD was 4.3 (95% CI 1.9-8.57). DISCUSSION AND CONCLUSION: This prospective follow-up study found children with ADHD to be at higher risk of later schizophrenia than controls. If replicated, these results warrant increased focus on the possible emergence symptoms of schizophrenia or schizophreniform psychosis during clinical follow-up of patients with ADHD.

Use of ADHD drugs in the Nordic countries: a population-based comparison study.

OBJECTIVE: To compare national use of attention-deficit/hyperactivity disorder (ADHD) drugs between five Nordic countries. METHOD: A population-based drug utilisation study based on nationwide prescription databases, covering in total 24 919 145 individuals in 2007. ADHD drugs defined according to the World Health Organization Anatomic Therapeutic Chemical classification system as centrally acting sympathomimetics (N06BA). RESULTS: The 2007 prevalence of ADHD drug use among the total Nordic population was 2.76 per 1000 inhabitants, varying from 1.23 per 1000 in Finland to 12.46 per 1000 in Iceland. Adjusting for age, Icelanders were nearly five times more likely than Swedes to have used ADHD drugs (Prev.Ratio = 4.53, 95% CI: 4.38-4.69). Prevalence among boys (age 7-15) was fourfold the prevalence among girls (Prev.Ratio = 4.28, 95% CI: 3.70-4.96). The gender ratio was diminished among adults (age 21 +) (Prev.Ratio = 1.24, CI: 1.21-1.27). CONCLUSION: A considerable national variation in use of ADHD drugs exists between the Nordic countries.

Empirical support for a reclassification of eating disorders NOS.

OBJECTIVE: To explore the empirical support for a reclassification of the eating disorders NOS (EDNOS) category. METHODS: In a cross-sectional design eight specific subgroups of EDNOS were compared to anorexia nervosa (AN) and bulimia nervosa (BN) on interview-based data and questionnaire measures. The sample consisted of 965 patients in the age 13-54 years admitted to treatment for an eating disorder. RESULTS: According to the DSM-IV 176(18%) presented with AN, 290(30%) with BN and 499(52%) with EDNOS. Of all EDNOS cases 34% could be reclassified as AN or BN. Three specific subgroups emerged as separate diagnostic entities. A heterogeneous subgroup of 122 patients (13% of all) was proposed as 'true' EDNOS. Implications of the results on the DSM-V are discussed. CONCLUSIONS: The results support a broader definition of AN and BN and suggest subgroups of EDNOS as separate diagnostic entities. This results in a substantial reduction of the heterogeneous EDNOS group.

Trans-diagnostic outcome of eating disorders: A 30-month follow-up study of 629 patients.

OBJECTIVE: To assess the 30-month outcome and predictors of outcome in a cohort of patients with any eating disorder (ED). METHOD: A naturalistic design was used to determine time to remission, predictors of remission, relapse, diagnostic cross-over and mortality of 629 patients. RESULTS: At follow-up (FU) 312 patients attended, 42% obtained full remission and 72% partial remission. No differences were found between diagnostic groups for adolescents. Adult patients with anorexia-like eating disorder not otherwise specified-anorexia nervosa (EDNOS-AN) had the poorest outcome. Bulimia-like EDNOS was the most frequent relapse diagnosis. Bingeing/purging behaviour predicted a poorer outcome for individuals with bulimic disorders. Desired low BMI predicted a poorer outcome for individuals with anorexia. Comorbid personality disorder was a common predictor of a worse outcome. CONCLUSION: Adults with EDNOS-AN had the poorest prognosis. Bulimic symptoms emerged frequently during FU regardless of diagnosis. Remission rates and outcome predictors were similar to previous findings.

Gestational age, birth weight, and the risk of hyperkinetic disorder.

AIMS: To study the association between gestational age and birth weight and the risk of clinically verified hyperkinetic disorder. METHODS: Nested case-control study of 834 cases and 20 100 controls with incidence density sampling. RESULTS: Compared with children born at term, children born with gestational ages of 34-36 completed weeks had a 70% increased risk of hyperkinetic disorder (rate ratio (RR) 1.7, 95% confidence interval (CI) 1.2 to 2.5). Children with gestational ages below 34 completed weeks had an almost threefold increased risk (RR 2.7, 95% CI 1.8 to 4.1). Children born at term with birth weights of 1500-2499 g had a 90% increased risk of hyperkinetic disorder (RR 1.9, 95% CI 1.2 to 2.9), and children with birth weights of 2500-2999 g had a 50% increased risk (RR 1.5, 95% CI 1.2 to 1.8) compared with children born at term with birth weights above 2999 g. The results were adjusted for socioeconomic status of the parents, family history of psychiatric disorders, conduct disorders, comorbidity, and maternal smoking during pregnancy. Results related to birth weight were unchanged after adjusting for differences in gestational age. CONCLUSIONS: Children born preterm, also close to term, and children born at term with low birth weights (1500-2499 g) have an increased risk of clinically verified hyperkinetic disorder. These findings have important public health perspectives because the majority of preterm babies are born close to term.

Psychopharmacological treatment with lithium and antiepileptic drugs: suggested guidelines from the Danish Psychiatric Association and the Child and Adolescent Psychiatric Association in Denmark.

A subcommittee under the Danish Psychiatric Association and the Child and Adolescent Psychiatric Association in Denmark have recently developed national guidelines for the psychopharmacological treatment with lithium and antiepileptic drugs, and the present translation aims at contributing to the international discussion on the development of proper guidelines for the treatment of bipolar disorder. Among the antiepileptic drugs, the report deals with valproate, carbamazepine and lamotrigine and to a lesser extent with oxcarbazepine, gabapentin and topiramate. The various drugs will be reviewed, outlining the scientific evidence for mood-stabilizing properties and discussing major side effects, the most important interactions with other drugs and practical use. Special considerations during pregnancy and lactation, during treatment of children and adolescents and during treatment of the elderly will also be presented. Antidepressants and antipsychotics are beyond the scope of the report, but due to the mood-stabilizing properties of at least some of the atypical antipsychotics, these agents will be brought into some focus in connection with the overall treatment guidelines for the different phases of bipolar disorder given at the end of this report.

Long-term experience with citalopram in the treatment of adolescent OCD.

OBJECTIVE: The primary purpose of the study was to describe tolerability and effectiveness of citalopram in the treatment of adolescent obsessive-compulsive disorder (OCD). METHOD: Thirty nondepressed patients (15 females, 15 males) with a mean age of 13.7 years (range 13-18 years) were treated for their OCD with citalopram in an open-label, flexible-dose study (range of dose 20-70 mg; mean dose 46.5 mg). All patients were referred to Aarhus University Hospital. The patients were monitored for 1 to 2 years. The mean total score on the Yale-Brown Obsessive Compulsive Scale (child or adult version) was 28.7 at base-line, 23.3 after 10 weeks of treatment, 20.0 after 6 months, 18.4 after 1 year, and 17.9 after 2 years (from baseline to 2 years of treatment: t = 11.65; p < .001). RESULTS: Seventy percent showed a decrease in total Yale-Brown Obsessive Compulsive Scale score in excess of 35% from baseline to 1 year of treatment. Twenty percent still had a score of greater than 20 after 1 year of treatment, indicating that clinically they still had OCD. Side effects were similar to those reported from the use of other selective serotonin reuptake inhibitors (SSRIs). No patient was excluded because of serious side effects during the 1 year of observation. CONCLUSIONS: The clinical effectiveness and tolerability of citalopram in the long-term treatment seem to be comparable with the observations of other SSRIs in childhood and adolescent OCD. A further, statistically significant reduction is provided by an extended treatment period of up to 1 year.

Obstetric complications and risk for severe psychopathology in childhood.

The purpose of the study was to assess the association of obstetric complications with risk for mental disorders resulting in hospitalization before the age of 15. Records from all births in Denmark from 1973 through 1993 were linked to records of all psychiatric hospitalizations. Diagnoses were grouped into seven broad categories. A reference population of 10% of births in Denmark from 1973 to 1990 was used for comparison. Obstetric complications were associated with the range of mental disorders occurring in childhood. The strongest predictors were a variable indicating the interaction of birth weight with speed of growth and the 5-minute Apgar score. There was no diagnostic group that stood out as different with respect to obstetric complications. These results are consistent with the hypothesis of the continuum of reproductive casualty.

[Evidence-based treatment of ADHD/DAMP in children and adolescents with central stimulants]. / Evidensbaseret behandling af ADHD/DAMP-børn og unge med centralstimulerende medicin.

The use of stimulants in the treatment of children and adolescents with Attention Deficit Hyperactivity Disorder, ADHD, and Deficit in Attention, Motor Control and Perception, DAMP, is often considered somewhat controversial. It was first used in 1937, and since the 1960s, 3000 published studies and 250 reviews have demonstrated the positive, short-term effect of stimulants on children and adolescents with ADHD/DAMP. More than 160 randomised, controlled trials (RCT) have studied the effect of attention, hyperactivity, and impulsivity. Furthermore, stimulants have proved effective on the social relation of such children, both in their families and in with their peers. Side effects are often mild, transient and dose-related. The short-term effectiveness of stimulants is thus well-documented and their prescription evidence-based, whereas further studies on the long-term effect are needed.

Reassessment of ADHD in a historical cohort of children treated with stimulants in the period 1969-1989.

The operational diagnostic criteria for ADHD or HKD were not at hand in Denmark before 1994, when WHO's International Classification of Diseases -10 (ICD-10) was introduced. The criteria for ADHD/HKD were well known at our clinic, but when treating children with stimulants the criteria used clinically prior to 1994 were less specific than today. The aims of this paper are to examine the prevalence of ADHD in a historical cohort of children treated with stimulants during the period 1969-1989 and to reassess a wide range of comorbid disorders and sociodemographic characteristics in order to compare aspects of the given treatment with the modern recommendations. At our clinic 208 children (183 boys) were given stimulants during the period 1969-1989. Case records on these probands were reassessed retrospectively for DSM-IV criteria regarding ADHD and comorbid disorders as well as for characteristics of stimulant treatment. Sixty-five percent met full criteria for an ADHD diagnosis. Including Subthreshold ADHD as many as 81 % of the cohort were re-diagnosed with ADHD. Prevalence rates of conduct problems and anxiety disorder were similar to previous prospective ADHD studies. The use of stimulants during the period 1969-1989 were in accord with modern guidelines. This cohort is comparable to other clinically based ADHD cohorts as regards inattentive, hyperactive/impulsive symptoms, comorbidity, impairment, gender differences, intelligence and socio-economic status (SES).

Gilles de la Tourette syndrome in a child with congenital deafness.

We present the case of a 10-year-old boy, Sam, with congenital deafness and Gilles de la Tourette Syndrome (GTS). GTS is characterised by multiple motor tics and one or more vocal tics that wax and wane. Due to his deafness Sam never developed vocal language but instead used sign language from the age of four. His tic disorder rapidly accelerated from the age of seven over a six-month period and soon sign language was incorporated into tics as complex "vocal" tics. Bursting out "words" in sign language would also occur in front of people unfamiliar with sign language and often with an obscene content although this was not evident to someone not trained in sign language. To our knowledge this is the first reported case of a congenital deaf child with GTS. The case presented here supports previously published work that the intentional share of the tics in GTS is very small. This case also questions former theories on which regions and circuits of the brain are involved in GTS.

Obsessions: the impact and treatment of obsessive-compulsive disorder in children and adolescents.

In the development of the majority of children, ritualistic behaviour may be seen as a normal phenomenon. In some children and adolescents, however, these rituals become time-consuming, interfering, irritating and annoying. The most common obsessions in both children and adults with obsessive-compulsive disorder (OCD) are related to a fear of dirt and contamination, fear of some terrible happening, and the fear of harming a loved one. The most common compulsions are washing fixations, checking behaviour and rituals (including mental rituals). Prevalence studies show that OCD in children and adolescents is far more common than previously thought. It is estimated that up to 2% of this population have symptoms fulfilling OCD criteria. The impact of early OCD onset can be profound, with long-term studies indicating that approximately 50% of these patients will also suffer from OCD in early adulthood. These patients tend to remain socially isolated, to have fewer relationships than their non-OCD peers, and have a tendency to remain within the family home during early adulthood. In addition, childhood OCD is associated with comorbid psychiatric disorders, in particular depression, anxiety and panic disorders, Tourette's syndrome and eating disorders. Treatment strategies for childhood OCD reflect those used in adult psychiatry. The most effective psychotherapeutic approach is based on cognitive-behavioural therapy with exposure and prevention. In contrast to pharmacotherapeutic agents without serotonin activity, the serotonin-specific antidepressants appear to be effective and well-tolerated in the treatment of OCD in children.

[Refugee and immigrant children referred to a department of pediatric psychiatry during the years 1991-1994]. / Flygtninge- og indvandrerbørn henvist til et børnepsykiatrisk hospital i årene 1991-1994.

The purpose of this study was to describe a group of 42 refugee- and immigrant children up to 14 years old compared to Danish controls in order to identify groups at risk and describe course, examination, treatment and contact. The investigation was based on case records. The only statistically significant results were higher frequencies of referral than expected regarding children from Lebanon and Somalia. However, the data indicate differences between the foreign and Danish groups as to greater problems of speech and language and less behavioural and emotional problems among the foreigners. No foreign children were offered foster homes. The attitudes of the parents towards referral, examination and treatment are more negative in the foreign group. The need for more research is emphasized.