Patterns and correlates of expressed emotion, perceived criticism, and rearing style in first admitted early-onset schizophrenia spectrum disorders.

The aim of this study was to assess patterns and correlates of family variables in 31 adolescents treated for their first episode of a schizophrenia spectrum disorder (early-onset schizophrenia [EOS]). Expressed emotion, perceived criticism, and rearing style were assessed. Potential correlates were patient psychopathology, premorbid adjustment, illness duration, quality of life (QoL), sociodemographic variables, patient and caregiver "illness concept," and caregiver personality traits and support. Families were rated as critical more frequently by patients than raters (55% vs. 13%). Perceived criticism was associated with worse QoL in relationship with parents and peers. An adverse rearing style was associated with a negative illness concept in patients, particularly with less trust in their physician. Future research should examine perceived criticism as a predictor of relapse and indicator of adolescents with EOS who need extended support and treatment. Rearing style should be carefully observed because of its link with patients' illness concept and, potentially, to service engagement and medication adherence.

From outside to inside to outside: Comments on intrapsychic representations and interpersonal interactions.

The external world is represented intrapsychically in a specific way. Following the age of an infant, for example, the structure, quality, and the degree of symbolization will be different. The term representation in science is filled with different contents. In psychoanalysis, we see a development from Sigmund Freud's "(Sach- or Wort-)Vorstellungen" to internal objects, then to self-object representations and finally-following newer results of the concept of intersubjectivity and especially under the influence of infant mental- and interactional research-to self-object interaction representations. Some aspects of this development are presented more in detail. Knowing that on one hand, interaction in external reality is structured by the self-object interaction representations of each interacting partner and that on the other hand, what happens during the interactions in external reality modifies the representational world of all the interactive persons (i.e., their inner reality), one can observe constant movements from inside to outside (e.g., transference, action) and from outside to inside of the individual (e.g., perception, stimulation, containment, modification). Clinical implications for the actual way of understanding are manifold, but are here only very shortly delineated.

Interfaces between intersubjectivity and attachment: Three perspectives on a mother-infant inpatient case.

Despite much new literature on clinical early intervention, background theoretical issues have received less critical attention. In this study, we look at a single mother-infant case from different perspectives. To give the discussion a viable focus, we draw upon two types of specific material: an Adult Attachment Interview (M. Main & R. Goldwyn, 1985-1998) and a video of mother-infant interaction. We elaborate some alternative conceptualizations of this material, noting similarities, contrasts, and differences in emphasis in these frameworks. A brief series of practical implications for clinical treatment is summarized in conclusion.

Acute stress reactions in the first 3 weeks postpartum: a study of 219 parturients.

OBJECTIVES: There is increasing research on posttraumatic stress (PS) 4-6 weeks and 3 months postpartum, but, there are no data on acute stress reactions (ASR) in the first 3 weeks postpartum, i.e. the potential precursors of PS. However, ASR may have long-term effects, e.g., on a subsequent pregnancy without having manifested as PS in the meantime. We propose: (i) to describe the patterns of ASR after childbirth, (ii) to explore differences between women with normal and traumatogenic ASR, and (iii) to provide data on the early detection of traumatogenic ASR 2 and 3 weeks postpartum. STUDY DESIGN: Intra-event variables (relationship with caregivers, overall birth experience, and dissociative experiences, as well as obstetric variables) were assessed 48-96 h. postpartum, as were ASR (by means of the Impact-of-Event Scale IES) in weeks 1, 2, and 3 postpartum. According to research on PS the upper 33%-range of ASR in weeks 2 and 3 was defined as 'traumatogenic'. RESULTS: Normal ASR in week 1 are at a level which in non-obstetric trauma-situations is considered as the upper range of low stress or lower range of medium distress. ASR decline constantly from week 1 to week 3. However, high ASR in week 1 do not drop faster than do low ones, thus indicating a prolonged stress reaction in women with high ASR in week 1. Low ASR (IES-scores <10) and high ASR (IES-scores >20) in week 1 are highly predictive for normal ASR, and traumatogenic ASR in weeks 2 and 3, respectively. Medium ASR (IES-scores 10-20) in week 1 are of uncertain predictive value for stress reactions in weeks 2 and 3 and have to be re-assessed at that time. CONCLUSIONS: Clinical screening for ASR appears to be helpful in detecting women with a compromised ability to process childbirth-related stress. The association between ASR and long-term development should be further explored.

[Psychoanalytic psychotherapy and the ADHD-triad (impulsivity, hyperactivity and attention deficit disorder)]. / Psychoanalytische Psychotherapie und ADHD-trias (Impulsivität, Hypermotorik und Aufmerksamkeitsstörungen).

A brief survey of the psychoanalytically oriented literature regarding the symptom triad of ADHD is followed by the discussion of frequently found disturbances in infantile development, attachment, object relations (regulation of drives and affects, ego functions) of the role of infantile trauma (object loss) and psychic conflict. In the analytic-psychotherapeutic process with a child, the ADHD-symptom-triad may manifest itself e.g. as intrapsychic conflict on the level of the self-representation or of the representation of central self-object-relations (characterized by an insufficient containing-/holding-function), as impairment of self-regulative functions, as inconsistent symbolizing capacity or as deficient regulating and controlling capacity of the ego. The multitude of factors involved does not allow a generalisation of neither the etiology or the pathogenesis of this symptom triad. This is particularly evident in a therapeutic procedure which is relation oriented. In a first interview the authors illustrate the capacity of a ten year old boy (diagnosed as ADHD patient) to make use of the analytic therapeutic dialogue and to present his intrapsychic experiences and problems in a figurative and narrative performance. Finally some specific technical features of low or high frequent analytic psychotherapy with ADHD children are shown: according to the foremost pregenital form of relations--manifested mostly by intensive self esteem problems, narcissistic aggressiveness and motor impulsivity--the transference and counter-transference movements proceed predominantly by projective and introjective identifications. Containment of the difficulties by the therapist is often paralleled for a long period of time by assistance in regulation and by limit setting for the child. Translation of action into language and transformation of intrapsychic processes within the psyche of the therapist into helpful interventions for the child require a continuous adjustment to the inconsistent ego functions and the fragile self esteem of the child. The additional use of stimulant drugs, the work within the family and/or the social context and the high need for research in the analytical field are briefly discussed at the end.

Associations between behavioral/emotional difficulties in kindergarten children and the quality of their peer relationships.

OBJECTIVE: The aim of this study was to investigate the associations between children's difficulties (conduct problems, hyperactivity/impulsivity, and emotional symptoms) and peer victimization and rejection in kindergarten. For the assessment of children's difficulties, the authors used a multi-informant approach. METHOD: A total of 153 five-year-old children were interviewed (Berkeley Puppet Interview). Teachers and parents completed the Strengths and Difficulties Questionnaire. Teachers reported on peer victimization. Peer nominations (rejection and acceptance) were conducted in a subgroup of 92 children. Combining teacher, parent, and self-reports of children's difficulties, three components were established: trait (degree of problems), informant differences resulting from perspective (self versus others), and context (kindergarten versus home). RESULTS: Children's difficulties were significantly associated with teacher- and self-reported victimization and peer rejection (r = 0.20-0.35), but not with peer acceptance. Conduct problems and emotional symptoms, but not hyperactivity/impulsivity, contributed independently to the variance of peer victimization and rejection. Perspective differences between children and adults according to hyperactivity/impulsivity also predicted peer rejection. CONCLUSION: Behavioral and emotional difficulties as well as a lack of self-awareness regarding hyperactive/impulsive behavior may place children at risk of peer victimization and rejection. Child psychiatric assessments and therapeutic strategies should thus take children's self-perception of symptoms and their peer relationships into account.

Depressive symptoms and psychosocial stress across the transition to parenthood: associations with parental psychopathology and child difficulty.

The transition to parenthood is often accompanied by depression and stress. Several studies have established risk factors for postpartum depression, e.g., antenatal depression. However, only a few studies have involved fathers. Moreover, most studies focus on the prevalence of depression instead of intraindividual changes over time. Our study investigated differential effects of parental psychopathology and child difficulty on the course of depressive symptoms and feelings of stress for first-time mothers and fathers. Seventy-four mothers and 58 fathers completed questionnaires on depressive symptoms (EPDS) and feelings of stress during pregnancy, and at 1, 3, 12, and 18 months postpartum. Parents rated children's difficulty-fussiness at 3, 12, and 18 months postpartum (ICQ). Parental psychopathology was established during pregnancy using self-reports (SCL-90-R) and anamnestic data. In mentally healthy mothers and fathers depressive symptoms decreased from pregnancy to 18 months postpartum, whereas parents with psychopathology in pregnancy showed a tendency to prolonged depressive phases. In parents with psychopathology, feelings of stress peaked at 12 months postpartum. Child difficulty was associated with elevated levels of psychosocial stress, but only for some participants. Parental psychopathological symptoms during pregnancy should thus be considered as a risk factor for elevated and prolonged depression and elevated psychosocial stress in mothers and fathers across the transition to parenthood.

Parental capacities for triadic relationships during pregnancy: Early predictors of children's behavioral and representational functioning at preschool age.

This study examines associations between parental capacities for triadic (mother-father-child) relationships, assessed prenatally, and the representational and behavioral functioning of their offspring at preschool age. Thirty-eight parental couples were given an intensive psychodynamic interview during their first pregnancy to assess how they anticipated their future parenthood and their relationships as threesomes (mother-father-child). The capacity for triadic relationships ("triadic capacity") was defined as the capacity of fathers and mothers to anticipate their family relationships without excluding either themselves or their partners from the relationship with the infant. Four years later, the representational and behavioral functioning of their children were assessed in depth using child narrative interviews and parental behavior ratings. The coherence of the children's narratives and the number of positive themes they expressed were significantly negatively correlated with the number of behavioral problems. In the longitudinal analyses, there were significant positive correlations between the parental triadic capacities and the coherence/number of positive themes in the children's narratives whereas parental triadic capacities showed a significant negative correlation with the number of the children's externalizing problems. The significance of triadic relational family processes for the development of children's representational world and behavioral functioning is discussed. ©2005 Michigan Association for Infant Mental Health.

How do obstetric variables influence the dimensions of the birth experience as assessed by Salmon's item list (SIL-Ger)?

OBJECTIVE: To analyse the effect of obstetric variables on four dimensions of the birth experience. DESIGN/PARTICIPANTS: The birth experience of 251 German-speaking women was assessed at 48-96 h postpartum by means of Salmon's item list--German-language version (SIL-Ger). METHOD/MAIN OUTCOME MEASURES: Statistical correlations and variances between four dimensions of the birth experience (fulfillment, emotional adaptation, negative emotional experience, physical discomfort) and common obstetric variables were calculated. The explained variance is assessed by a stepwise regression analysis. RESULTS: In general the variance explained by the investigated obstetric variables per se is low. The mode of delivery affects the dimension of negative emotional experience with a constant qualitative worsening in the order of spontaneous deliveries, instrumental deliveries, elective and unplanned caesarean sections. Epidurals are associated neither with positive nor with negative evaluative feelings. To assess the impact of duration, the subjective latent phase of labour has to be taken into consideration in addition to the duration of labour itself. Not only very long durations of labour, but also very short ones may induce negative evaluative feelings in the immediate postpartum. CONCLUSIONS: Further research on this question must include the aspect of the parturients' subjective perception of both obstetric procedures and the attending staff. Clinicians should be aware that epidurals and elective caesarean sections do not necessarily enhance positive evaluative feelings in the immediate postpartum.

Parental psychopathology, marital quality, and the transition to parenthood.

This study of 80 expectant first-time parents investigated the associations among marital quality, parental psychiatric disorders, and parents' capacity to form triadic relationships (Triadic Capacity). The results suggest that marital quality as well as maternal and paternal psychopathology affect child and family development as early as pregnancy, when parents prepare themselves to integrate the future child into their relational world.

[Should an adolescent psychiatric clinic be managed as an open setting? Initial evaluation of 7 years experiences]. / Soll eine Jugendpsychiatrische Klinik offen geführt werden?--Erste Auswertung von sieben Jahren Erfahrung.

After a controversial discussion, the adolescent department of the child and adolescent psychiatry clinic of the university of Basle (KJUP) opened seven years ago as an open ward for the treatment of acute psychiatric breakdowns in adolescents. Meanwhile more than 22.000 days of care have been provided. The patients suffered from the whole range of psychiatric illnesses. The lack of possibilities to engage in an examination of security measures lead to an increased involvement in relationships between patients and his/her parents and the staff. Yet there are limits in treating psychiatric patients in an open ward. A conditio sine qua non is the possibility to hospitalize patients in peaks of crisis in the locked ward of the adult department of the university clinic. In the first seven years, 13 patients had to be transferred to the locked ward for a total of 0.05@1000 of the days of care, 6 of whom returned to the adolescent department after a short while (2.6 days in average). In the rest of the time, the advantages of an open setting could be used to the full extent.

[Discontinuation of treatment in child and adolescent ambulatory psychiatric care in Basel: an evaluation within the scope of quality assurance]. / Behandlungsabbrüche in einer kinder- und jugendpsychiatrischen Ambulanz in Basel: eine Evaluation im Rahmen der Qualitätssicherung.

Attrition in child and adolescent psychiatry occurs frequently and has often been investigated. Attempts to establish general criteria that are associated with dropping-out have produced contradictory results. In the present study, factors that influenced attrition at a child psychiatry outpatient clinic in Basel were assessed during two separate periods. Between the two assessments, the results of the first period were presented to the staff and were discussed. At first assessment, attrition was increased in patients who were referred as emergencies or by somatic hospitals. In contrast, attrition was low in patients who were referred involuntarily. At second assessment, there was a significant decrease in dropping-out for the total sample and for emergencies. This result may be explained by a more careful clarification of the setting before first consultation and, as a consequence, by higher congruence between patients' expectations and the clinic's offers. Further studies on the subject of attrition in child and adolescent psychiatry should focus on clearly defined clinical situations and samples and include measures of patients' expectations as well as of the therapeutic relationship.

["Operationalised psychodynamic diagnostics in childhood and adolescence" (OPD-CA) in practice]. / Die "Operationalisierte Psychodynamische Diagnostik im Kindes- und Jugendalter" (OPD-KJ) in der Praxis.

"Operationalised psychodynamic diagnostics in childhood and adolescence" (OPD-CA) has been completed in its first version after years of development. In a first interview with a 13-year-old boy, the diagnostic instruments of OPD-CA are presented by means of examples. The text passages of the transcribed first interview are evaluated in four sections by representatives of the respective working groups regarding the axes--relationships, conflict, structure and preconditions for treatment--and the diagnostic conclusions resulting from this are presented, thus providing a direct insight into the specific psychodynamic diagnostics of OPD-CA.

[Indications for inpatient child and adolescent treatment]. / Zur Indikation einer stationären jugendpsychiatrischen Behandlung.

When the demand for inpatient treatment in acute psychiatric crisis of adolescents rises, it is not always recommended to admit a patient to the hospital. The limited number of hospital beds forces medical professionals to use their resources cautiously. This leads to the need to activate the intrapersonal and intrafamilial resources. The motivation for change emerging out of a crisis is to be used for clarification of the indication of inpatient treatment and of the order of treatment, a patient (and/or his legal representative) gives to the hospital representatives. A clarification of the aims of a hospitalisation prior to the admission to the ward rises the efficacy of the invested time.

[Siblings of children with cancer: integration of illness experiences into personal life history]. / Geschwister krebskranker Kinder: Die Integration der Krankheitserfahrungen in die persönliche Lebensgeschichte.

Based on the hypothesis that personal narratives help to cope people with stressful life events, 33 adult siblings of former childhood cancer patients were asked how they had experienced illness and treatment of their brother or sister. Analysis of the narratives was used to measure the integration of these experiences into personal biography. Good integration correlated positively with good body concepts. Siblings with good integration also scored lower for fatalistic health locus of control and perceived the illness retrospectively as more distressing than those with poor integration. In contrast, integration did not correlate with distress evoked by present feelings towards illness and therapy or by thoughts of a relapse or a personal cancer illness. The findings of this exploratory investigation may suggest that successful integration of the experiences associated with a brother's or sister's cancer is associated with a trustful relation to the own body and with the ability to accept painful feelings and to allow them to emerge. Assisting siblings of young cancer patients to create and maintain their personal narratives of their experiences can make an important contribution to coping.

Basic symptoms in the general population and in psychotic and non-psychotic psychiatric adolescents.

OBJECTIVE: Cognitive-perceptive 'basic symptoms' are used complementary to ultra-high-risk criteria in order to predict onset of psychosis in the pre-psychotic phase. The aim was to investigate the prevalence of a broad selection of 'basic symptoms' in a representative general adolescent population sample (GPS; N=96) and to compare it with adolescents first admitted for early onset psychosis (EOP; N=87) or non-psychotic psychiatric disorders (NP; N=137). METHODS: Subjects were assessed with the Bonn Scale for the Assessment of Basic Symptoms (BSABS). Prevalence of at least one 'basic symptom' and mean numbers were compared across the three groups. Logistic regression was used to predict group membership by BSABS subscales; risk ratios were calculated to identify 'basic symptoms' which best discriminated between groups. RESULTS: The prevalence of at least any one 'basic symptom' was 30.2% in GPS compared to 81% in NP and 96.5% in EOP. Correct classification of EOP when compared to GPS was high (94.0%) and lower when compared to NP (78.6%). Cognitive symptoms discriminated best between EOP and NP. CONCLUSION: Alike other prodromal- and psychotic-like experiences, 'basic symptoms' are prevalent in the general adolescent population, yet at a lower rate compared to EOP and NP. The usage of 'at least one basic symptom' as a screening criterion for youth at risk of developing a psychotic disorder is not recommended in the general population or in unselected psychiatrically ill adolescents. However, particularly cognitive 'basic symptoms' may be a valuable criteria to be included in future 'at risk' studies in adolescents.

Mental health problems in children of somatically ill parents, e.g. multiple sclerosis.

OBJECTIVES: Based on the investigation of 144 families (144 patients affected by Multiple Sclerosis (MS), 109 partners, and 192 children) examined in three different European child and adolescent psychiatric University centres by means of questionnaires, we evaluated the prevalence of psychological symptoms in the offspring and associated risk factors such as duration and severity of the disease as well as depression of the ill and the healthy parent. RESULTS: Indicate that the severe disease of MS is associated with depression of the ill and healthy parent. Ill parents, especially ill mothers, as well as depressed ill, or depressed healthy parents evaluate their children's mental health problems with a higher prevalence within the internalizing spectrum. Healthy parents report normal psychological adjustment of their children. If two parents present a depressive state, the prevalence of relevant psychological internalizing symptoms is twice or three times as high as the age norms. CONCLUSION: Children in families with a parent affected by MS and associated depression of the parental couple are at high risk of mental health problems, especially internalizing disorders. In focusing on the mental health of children one must also be aware of the potential opportunities to address the parents' own psychological needs.

Intergenerational transmission of marital quality across the transition to parenthood.

One of the most frequently reported changes across the transition to parenthood is a decline in marital quality after the birth of a first baby. Experiences in the family of origin may influence the trajectory of marital quality. Our study aimed to investigate the impact of recollections of family-of-origin marriage on marital quality (self-reports and clinical evaluation) from pregnancy to 1 year after the birth of a first child. A total of 62 first-time parents completed questionnaires (self-reported marital satisfaction) and clinical interviews (clinical evaluation of couples' dialogue quality). Although self-reported marital satisfaction and observed dialogue quality were highly associated, only self-reported marital satisfaction declined from pregnancy to 1 year after birth. This decrease was partly due to very high marital satisfaction during pregnancy. Different trajectories for self-reported marital satisfaction and observed dialogue quality were found for participants with recollections of low-, average-, and high-quality family-of-origin marriage. A structural equation model showed that participants who recollected a negative quality in their parents' relationship reported more negative changes in the quality of their own marriages. There seems to be an intergenerational transmission of marital quality that comes to light when couples are challenged by the birth and rearing of a baby.

The years after: a concept of the psychological integration of childhood cancer.

GOALS OF WORK: To define and measure the psychological integration of childhood cancer experiences into a personal biography and to explore the association between integration with illness-related factors and psychosocial conditions. PATIENTS AND METHODS: Analysis of cancer survivors' narratives on the course of their illness was used to measure integration. Psychosocial condition, body concepts, health locus of control, and illness-related distress were evaluated by questionnaires. Illness factors were assessed by reviewing hospital case notes and sociodemographic factors by a structured interview. Of 72 eligible subjects contacted, 60 agreed to participate. MAIN RESULTS: High inter-rater correlations established the reliability of the concept of testing integration by narrative analysis. Subjects with good psychological integration of the experience of cancer saw chance as having less to do with illness and health, and perceived illness and therapy retrospectively as more distressing than survivors with poor integration. In contrast, integration did not correlate with distress evoked by present feelings toward illness and therapy or by thoughts of a relapse. CONCLUSIONS: Successful integration of the experience of cancer may be associated with the ability to accept painful feelings and to allow them to emerge, and with a readiness to accept responsibility in relation to health and medical care. Assisting young cancer patients and their families to create and maintain their personal narratives of the experience of illness is an important clinical task for all professionals working in paediatric oncology.