Clinicians' Adherence to Guidelines When Initiating Methylphenidate Treatment.

Aims: Between 2008 and 2012, the number of children and adolescents in the Netherlands who received methylphenidate prescriptions increased by 35.6%. We determined guideline adherence regarding the assessment of attention-deficit/hyperactivity disorder (ADHD) and rates of off-label use in those 2 years. We also compared adherence to guidelines between mental health and pediatrics settings. Methods: We conducted a medical file audit of 506 children or adolescents who had received a first methylphenidate prescription in 2008 (n = 208) or 2012 (n = 298) across mental health (n = 333) and pediatrics outpatient clinics (n = 173) in the Netherlands and assessed adherence to seven guideline recommendations. Results: We did not find significant differences between 2008 and 2012 regarding the mean adherence to the seven recommendations (43% vs. 45%) or the percentage of off-label use (35% vs. 30%). Best adherence rates (over the years 2008 and 2012 combined) concerned the assessment of comorbidities (89%) and the involvement of teachers in the diagnostic process (75%). Least frequently adhered to were assessing ADHD severity (1%), the use of a (semi-)structured parent interview (16%), and providing psycho-education to parents (42%) or teachers (1%). Mental health settings showed better adherence than pediatrics settings (over the years 2008 and 2012 combined) concerning the use of (semi-)structured parent interviews (22% vs. 3.1%), having a separate diagnostic session directed at the child (81% vs. 63%), assessment of comorbidities (95% vs. 76%), and providing psycho-education to parents (51% vs. 24%). Conclusions: There was neither a decrease in adherence to guidelines nor an increase in off-label use between 2008 and 2012. However, there is ample room for improvement regarding guideline adherence.

Long-term effectiveness of eye movement desensitization and reprocessing in children and adolescents with medically related subthreshold post-traumatic stress disorder: a randomized controlled trial.

AIMS: Medical procedures and hospitalizations can be experienced as traumatic and can lead to post-traumatic stress reactions. Eye movement desensitization and reprocessing (EMDR) shows promising results but very few long-term studies have been published. Therefore, our aim was to test the long-term (8 months post-treatment) effectiveness of EMDR in children and adolescents with medically related subthreshold post-traumatic stress disorder (PTSD). METHODS AND RESULTS: Seventy-four children (including 39 with congenital or acquired heart disease) aged 4-15 (M = 9.6 years) with subthreshold PTSD after previous hospitalization were included into a parallel group randomized controlled trial. Participants were randomized to EMDR (n = 37) or care-as-usual (CAU) (n = 37; medical care only). The primary outcome was PTSD symptoms of the child. Secondary outcomes were symptoms of depression and blood-injection-injury (BII) phobia, sleep problems, and health-related quality of life (HrQoL) of the child. Assessments of all outcomes were planned at baseline and 8 weeks and 8 months after the start of EMDR/CAU. We hypothesized that the EMDR group would show significantly more improvements on all outcomes over time. Both groups showed improvements over time on child's symptoms of PTSD (only parent report), depression, BII phobia, sleep problems, and most HrQoL subscales. GEE analyses showed no significant differences between the EMDR group (nT2 = 33, nT3 = 30) and the CAU group (nT2 = 35, nT3 = 32) on the primary outcome. One superior effect of EMDR over time was found for reducing parent-reported BII phobia of the child. CONCLUSION: EMDR did not perform better than CAU in reducing subthreshold PTSD up to 8 months post-treatment in previously hospitalized children. Possible explanations and clinical implications are discussed.

EMDR for children with medically related subthreshold PTSD: short-term effects on PTSD, blood-injection-injury phobia, depression and sleep.

Background: Paediatric illness, injury and medical procedures are potentially traumatic experiences with a range of possible negative psychosocial consequences. To prevent psychosocial impairment and improve medical adherence, evidence-based psychotherapy should be offered if indicated. Eye movement desensitization and reprocessing (EMDR) has been found to reduce symptoms of posttraumatic stress disorder (PTSD) in adults. The evidence for the use with children is promising. Furthermore, recent studies indicate its effectiveness for the treatment of other psychological symptomatology. However, the effectiveness of EMDR in children with subthreshold PTSD after medically related trauma has not yet been investigated. Objective: Investigating the short-term effectiveness of EMDR on posttraumatic stress, anxiety, depression and sleep problems in children with subthreshold PTSD after hospitalization through a randomized controlled trial (RCT). Method: Following baseline screening of 420 children from various Dutch hospitals, 74 children (4-15 years old) with medically related subthreshold PTSD were randomized to EMDR (n = 37) or care-as-usual (CAU; n = 37). Follow-up assessment took place after M = 9.7 weeks. Generalized Estimating Equation (GEE) analyses were performed to examine the effectiveness of EMDR compared to CAU. Results: Children in both groups improved significantly over time on all outcomes. However, the EMDR group improved significantly more as to child-reported symptoms of blood-injection-injury (BII) phobia and depression, and child-, and parent-reported sleep problems of the child. There was no superior effect of EMDR compared to CAU on subthreshold PTSD symptom reduction. Conclusions: EMDR did not perform better than CAU in reducing PTSD symptoms in a paediatric sample of children with subthreshold PTSD after hospitalization. However, the study results indicate that EMDR might be superior in reducing symptoms of blood-injection-injury phobia, depression and sleep problems.

Antecedentes: La enfermedad pediátrica, injuria y procedimientos médicos son experiencias potencialmente traumáticas con un rango de posibles consecuencias psicosociales negativas. Para prevenir el deterioro psicosocial y mejorar la adherencia médica, se debe ofrecer psicoterapia basada en evidencia si está indicada. Se ha observado que la Desensibilización y Reprocesamiento por Movimientos Oculares (EMDR) reduce los síntomas del Trastorno de Estrés Postraumático (TEPT) en adultos. La evidencia para su uso en niños es promisoria. Asimismo, estudios recientes indican su efectividad para el tratamiento de otra sintomatología psicológica. No obstante, la efectividad de la EMDR en niños con TEPT subumbral posterior a trauma médicamente relacionado aún no ha sido estudiada.Objetivo: Investigar la efectividad a corto plazo de la EMDR en estrés postraumático, ansiedad, depresión y alteraciones del sueño en niños con TEPT subumbral posterior a hospitalización, a través de un ensayo controlado aleatorizado (ECA).Método: Seguimiento de una muestra de 420 niños provenientes de varios hospitales holandeses, 74 niños (4­15 años de edad) con TEPT subumbral médicamente relacionado fueron aleatorizados a EMDR (n=37) o tratamiento habitual (TH, n=37). La evaluación posterior tuvo lugar tras M=9,7 semanas. Se realizó un análisis de ecuaciones de estimación generalizadas (EEG) para examinar la efectividad de EMDR comparado con TH.Resultados: Los niños en ambos grupos mejoraron significativamente a lo largo del tiempo en todas las variables. No obstante, el grupo EMDR mejoró significativamente más en los síntomas reportados por los niños respecto a belonefobia y depresión, y en alteraciones del sueño de los niños reportadas tanto por ellos como por sus padres. No hubo efecto superior de EMDR comparado con TH en la reducción de síntomas de TEPT subumbral.Conclusiones: EMDR no actuó mejor que TH en la reducción de síntomas de TEPT en niños en una muestra pediátrica de niños con TEPT subumbral posterior a hospitalización. Sin embargo, los resultados del estudio indican que EMDR podría ser superior en la reducción de síntomas de belonefobia, depresión y alteraciones del sueño.

[Panhypopituitarism in one identical twin: the effect of hormone replacement]. / Panhypopituïtarisme bij helft van identieke tweeling. Het effect van hormonale substitutie.

BACKGROUND: Panhypopituitarism in childhood is rare. It is even rarer if the disorder appears in a boy with an identical but healthy twin brother. In such a patient it is useful to study the consequences of the hormone disorder and the effect of hormone replacement. CASE DESCRIPTION: A 6-year-old boy saw a paediatrician because of short stature. He was much shorter than his identical twin brother and he had more abdominal fat mass and a smaller penis. Laboratory tests identified hypothyroidism of central origin, in combination with hypocortisolism and growth hormone deficiency. Hormonal replacement resulted in an improvement in growth rate. At the age of 15 years, testosterone therapy was introduced because puberty had not occurred and his growth rate was low. Finally the patient grew a few centimetres taller than his twin brother. CONCLUSION: In the first year of life, panhypopituitarism has no negative consequences for growth. After this point, growth is clearly delayed. With sufficient replacement growth can completely catch up.