A 15-year follow-up of former self-harming inpatients in child & adolescent psychiatry - a qualitative study.

Purpose: Self-harm is common among adolescents, and is even more frequent among psychiatric populations. The aim of this study was to increase knowledge and understanding of different aspects of life for adults who, when adolescents, had engaged in severe self-harm during inpatient stays.Material and methods: Individual semi-structured interviews were held with seven former inpatients with a history of severe self-harm during inpatient stay in their adolescence. The interviews were analysed using a qualitative method, and the results were described in the form of categories and sub-categories.Results: Five categories, with 16 sub-categories, were found to be related to the former patients' experiences of their lives. At the time of the interviews, the subjects were in their early thirties and had no ongoing self-harm. In childhood they had experienced a dysfunctional relationship with one or both of their parents, and self-harm was one of several destructive behaviours. Friendships outside the unit were difficult during adolescence. Soon after admission to the psychiatric inpatient unit, relationships with other patients became important and contributed to them wanting to stay at the unit. Meaningful relationships and being part of a social context with healthy expectations were seen as important factors for stopping self-harm at a later stage. The subjects' experiences of their life today ranged from not enjoying it to accepting their current situation.Conclusion: These findings are based on a small sample, but they indicate the importance of relationships and the social context in contributing to and then ending self-harm.

Annual Research Review: The state of implementation science in child psychology and psychiatry: a review and suggestions to advance the field.

BACKGROUND: Scientists have developed evidence-based interventions that improve the symptoms and functioning of youth with psychiatric disorders; however, these interventions are rarely used in community settings. Eliminating this research-to-practice gap is the purview of implementation science, the discipline devoted to the study of methods to promote the use of evidence-based practices in routine care. METHODS: We review studies that have tested factors associated with implementation in child psychology and psychiatry, explore applications of social science theories to implementation, and conclude with recommendations to advance implementation science through the development and testing of novel, multilevel, causal theories. RESULTS: During its brief history, implementation science in child psychology and psychiatry has documented the implementation gap in routine care, tested training approaches and found them to be insufficient for behavior change, explored the relationships between variables and implementation outcomes, and initiated randomized controlled trials to test implementation strategies. This research has identified targets related to implementation (e.g., clinician motivation, organizational culture) and demonstrated the feasibility of activating these targets through implementation strategies. However, the dominant methodological approach has been atheoretical and predictive, relying heavily on a set of variables from heuristic frameworks. CONCLUSIONS: Optimizing the implementation of effective treatments in community care for youth with psychiatric disorders is a defining challenge of our time. This review proposes a new direction focused on developing and testing integrated causal theories. We recommend implementation scientists: (a) move from observational studies of implementation barriers and facilitators to trials that include causal theory; (b) identify a core set of implementation determinants; (c) conduct trials of implementation strategies with clear targets, mechanisms, and outcomes; (d) ensure that behaviors that are core to EBPs are clearly defined; and (e) agree upon standard measures. This agenda will help fulfill the promise of evidence-based practice for improving youth behavioral health.

Core Competencies for Pediatric Consultation-Liaison Psychiatry in Child and Adolescent Psychiatry Fellowship Training.

BACKGROUND: Learners developing competency-based skills, attitudes, and knowledge through the achievement of defined milestones is a core feature of competency-based medical education. In 2017, a special interest study group of the American Academy of Child and Adolescent Psychiatry convened a panel of specialists to describe pediatric consultation-liaison psychiatry (CLP) best educational practices during child and adolescent psychiatry fellowship. OBJECTIVE: The objective of this project was to develop a national consensus on pediatric CLP competencies to help guide training in this specialty. METHODS: An expert working group developed a list of candidate competences based on previously established educational outcomes for CLP (formerly Psychosomatic Medicine), child and adolescent psychiatry, and general psychiatry. A survey was distributed to members of the American Academy of Child and Adolescent Psychiatry Physically Ill Child Committee to determine child and adolescent psychiatry fellowship educational needs on pediatric CLP services and generate consensus regarding pediatric CLP competencies. RESULTS: Most survey respondents were supportive of the need for a national consensus on core competencies for pediatric CLP. Consensus from a panel of experts in the field of pediatric CLP generated a list of proposed core competencies that track the Accreditation Council for Graduate Medical Education's six core competencies. CONCLUSIONS: Consistent learning outcomes provide the foundation for further development of tools to support training in pediatric CLP. There is a need to develop further tools including outcome assessment instruments and self-directed learning materials that can be used to support lifelong learning.

[Towards personalized child and adolescent psychiatry care by using routinely registered data from everyday clinical practice]. / Naar een gepersonaliseerde kinder- en jeugdpsychiatrie met registratiegegevens uit de dagelijkse zorgpraktijk.

BACKGROUND: Studying differences in the course and treatment effects of psychiatric disorders between subgroups of patients can provide suggestions to improve everyday clinical practice.
AIM: To illustrate how routinely registered data from child and adolescent psychiatry can be used to gain insight into differences in the development of patient groups.
METHOD: Multilevel analyses in four subgroups of youths with an autism spectrum disorder (asd; n = 1681; boys/girls, with/without comorbid psychiatric disorder) to investigate differences in the development of quality of life during the first six months of treatment.
RESULTS: Subgroups of youths with asd showed differences in development of quality of life, which can provide suggestions to establish personalized care.
CONCLUSION: Multicenter research in large samples is needed to investigate the robustness of our findings. The 'Research Data Infrastructure', containing routine outcome monitoring and electronic medical record data from more than 117.000 youths in child and adolescent psychiatry, offers a unique opportunity to perform large scale practice based research.

[Contract Focused Group Therapy - Results of a Second Evaluation]. / Auftragsfokussierende Gruppentherapie ­ Ergebnisse einer erneuten Evaluationsstudie.

Contract Focused Group Therapy - Results of a Second Evaluation Contract focused group therapy (AFoG) can be understood as a successful transformation of systemic solution focused mindsets into a group therapy concept for children and adolescents. The current evaluation study intents to investigate the effectiveness of AFoG. The sample size includes 72 children who attended AFoG and their parents. A pre-post-design was used to measure the perceived exposure of the child's problem behavior via caregiver report (CBCL 4-18) and self-report (YSR 11-18) at the beginning and three months after group therapy. Based on t-tests, the hypothesis that children and parents report significantly lower symptoms after finishing AFoG than at the beginning of the group therapy can be confirmed. Especially children and adolescents who were assessed as highly displaying several behavioral problems (t-values between 71-80), show a clear decrease in the perceived symptom load in both the self-report and the caregiver report. Moreover, the clinical significance of the decrease were examined by using the Reliable Change Index. In this sense, a positive effect is recorded. Further research inclusive a control group is needed to support the effectiveness of AFoG.

Editorial: Making clinical trials smarter (and more interesting).

At its heart, the field of child psychology and psychiatry is geared towards using science to develop interventions that promote children's healthy development and treat behavioural and emotional difficulties when they arise. While there have been some successes (e.g. stimulant medication for ADHD, parent training for child conduct problems, Fonagy et al., ) serious challenges lie ahead if we are to achieve reliable and lasting improvements for a larger number of children, and for a broader spectrum of problems.

Clinical decision support systems in child and adolescent psychiatry: a systematic review.

Psychiatric disorders are amongst the most prevalent and impairing conditions in childhood and adolescence. Unfortunately, it is well known that general practitioners (GPs) and other frontline health providers (i.e., child protection workers, public health nurses, and pediatricians) are not adequately trained to address these ubiquitous problems (Braddick et al. Child and Adolescent mental health in Europe: infrastructures, policy and programmes, European Communities, 2009; Levav et al. Eur Child Adolesc Psychiatry 13:395-401, 2004). Advances in technology may offer a solution to this problem with clinical decision support systems (CDSS) that are designed to help professionals make sound clinical decisions in real time. This paper offers a systematic review of currently available CDSS for child and adolescent mental health disorders prepared according to the PRISMA-Protocols (Preferred Reporting Items for Systematic Reviews and Meta-Analyses Protocols). Applying strict eligibility criteria, the identified studies (n = 5048) were screened. Ten studies, describing eight original clinical decision support systems for child and adolescent psychiatric disorders, fulfilled inclusion criteria. Based on this systematic review, there appears to be a need for a new, readily available CDSS for child neuropsychiatric disorder which promotes evidence-based, best practices, while enabling consideration of national variation in practices by leveraging data-reuse to generate predictions regarding treatment outcome, addressing a broader cluster of clinical disorders, and targeting frontline practice environments.

Psychiatric impairment ratings in children and adolescents.

OBJECTIVES: It is accepted practice in Australia and New Zealand for psychiatric impairment rating scales to be applied for persons claiming psychiatric injury. These scales were derived for adults, not children. There is less clarity as to whether and how these scales may be applied for children claiming psychiatric injury. METHODS: We review Australian and New Zealand guidelines and methods for assessing permanent psychiatric impairment, as they apply to children and adolescents. RESULTS: With significant caution, psychiatric impairment rating scales can be administered for children. Guidance and recommendations in this regard are provided. For some, the effects of psychiatric injury may not be stable, and permanent impairment assessment should be delayed until sufficient maturity occurs. CONCLUSIONS: Psychiatric impairment rating scales are widely applied for adults claiming psychiatric injury, however caution must be exercised when these scales are used in children.

Practitioner Review: On the trustworthiness of clinical practice guidelines - a systematic review of the quality of methods used to develop guidelines in child and youth mental health.

BACKGROUND: Numerous practice guidelines (PGs) relevant to child and youth mental health (CYMH) are available, but their quality is uncertain. We used systematic review methodology to identify the methods employed to develop PGs in CYMH and assess whether they align with international quality standards. METHODS: We used prespecified inclusion criteria to search for CYMH PGs (2009-2014) in journals of professional associations or websites of organizations who produce or house PGs. Eligible PGs and organization websites were screened to identify PG development methods. Two reviewers assessed the alignment of the PG development methods with PG quality criteria using the Appraisal of Guidelines for Research and Evaluation (AGREE II) domains and Institute of Medicine (IOM) standards. RESULTS: Five sets of eligible development methods were identified in 70 eligible PGs. Three sets adhered to all (National Institute for Health and Care Excellence; Scottish Intercollegiate Guidelines Network) or most (U.S. Preventive Services Task Force) AGREE II domains and IOM standards, and were used to develop 31.4% of PGs. The two remaining sets of development methods had important weaknesses (e.g. lack of mandatory rigorous systematic reviews, multidisciplinary development groups, or transparent conflict of interest methods) and were associated with 21.4% of PGs. No development methods could be identified in 40.0% of PGs; ineligible development methods were referenced in 7.1% of PGs. CONCLUSIONS: Up to 69% of available CYMH PGs may have been developed using methods that do not align with AGREE II quality criteria or IOM standards. The quality of available CYMH PGs needs to be assessed, and strategies designed to guide practitioners to high quality PGs and facilitate adherence by PG developers to international quality standards are needed.

Editorial Perspective: How should child psychologists and psychiatrists interpret FDA device approval? Caveat emptor.

Recently several new tests have received US Federal Drug Administration (FDA) marketing approval as aids in the diagnostic process for attention deficit hyperactivity disorder (ADHD), including the Neuropsychiatric electroencephalogram (EEG)-Based ADHD Assessment Aid (NEBA) Health test. The NEBA test relies upon an EEG-based measure, called the theta to beta ratio (TBR). Although this measure has yielded large differences between ADHD and non-ADHD groups in studies prior to 2009, recent studies and a meta-analysis could not replicate these findings. In this article, we have used the NEBA device as an exemplar for a discussion that distinguishes between FDA de novo marketing approval for a device and any claims that that device is empirically supported, scientifically validated with replicated findings. It is understood that the aims of each differ; however, for many, including the lay public as well as some mental health professionals, these terms may be confused and treated as though they are synonymous. With regard to the TBR measure, there is no reliable association or replication for its clinical usage in the ADHD diagnostic process. The recommendation for potential consumers of the NEBA Health test (as well as perhaps for other existing FDA-approved diagnostic tests) is caveat emptor (let the buyer beware!).

Annual Research Review: Threats to the validity of child psychiatry and psychology.

BACKGROUND: Suggestions have been made that many claims concern false-positive findings in the field of child psychology and psychiatry. FINDINGS: The literature was searched for concepts and findings on the validity of child psychiatry and psychology. Substantial progress has been made in some, but not all, areas and considerable challenges remain in all. CONCLUSIONS: The two major threats to validity concern the inability to examine brain tissues in life and the evidence that there is a high overlap among disorders. We emphasize the need to follow published guidelines on preplanned analyses and we note the dangers associated with unregulated flexibility in data analysis. We note the very important clinical and developmental findings that have been ignored, perhaps partly because of an excessive focus on technologies. Nevertheless, we are positive about both the accomplishments and the ways in which challenges are being met.

Canadian Network for Mood and Anxiety Treatments (CANMAT) 2016 Clinical Guidelines for the Management of Adults with Major Depressive Disorder: Section 6. Special Populations: Youth, Women, and the Elderly.

BACKGROUND: The Canadian Network for Mood and Anxiety Treatments (CANMAT) conducted a revision of the 2009 guidelines by updating the evidence and recommendations. The scope of the 2016 guidelines remains the management of major depressive disorder (MDD) in adults, with a target audience of psychiatrists and other mental health professionals. METHODS: Using the question-answer format, we conducted a systematic literature search focusing on systematic reviews and meta-analyses. Evidence was graded using CANMAT-defined criteria for level of evidence. Recommendations for lines of treatment were based on the quality of evidence and clinical expert consensus. This section on "Special Populations" is the sixth of six guidelines articles. RESULTS: Recent studies inform the treatment of MDD in children and adolescents, pregnant and breastfeeding women, women in perimenopause or menopause, and the elderly. Evidence for efficacy of treatments in these populations is more limited than for the general adult population, however, and risks of treatment in these groups are often poorly studied and reported. CONCLUSIONS: Despite the limited evidence base, extant data and clinical experience suggest that each of these special populations can benefit from the systematic application of treatment guidelines for treatment of MDD.

Child and adolescent sports psychiatry in the US.

A positive youth sports experience is essential if an athlete is to develop a lifelong commitment to sport. Children enjoy play and adults can create opportunities for physical, emotional, and cognitive development through sport for all children. This article reviews the current state of youth sports in the US, highlighting some of the problems of the current model and efforts to transform and improve the youth sports experience in the US. The new model of youth sports emphasizes the importance of developing 'physical literacy' in all young athletes, increasing availability of recreational sports activities, providing quality coaching to all, improved sports safety, improved availability of sports venues for athletes at all levels, and at an affordable cost for all. The US Olympic Committee, following an innovative programme by USA Hockey, has developed and promoted the American Developmental Model to its component Sport National Governing Boards to improve the experience of young athletes. The sports-informed paediatric psychiatrist, knowledgeable about child and family development and aware of the local youth sports opportunities and challenges, is well prepared to advocate for a healthy and fun sport experience for every young athlete.

Junior MARSIPAN (Management of Really Sick Patients with Anorexia Nervosa).

We present a review of the Junior MARSIPAN (Management of Really Sick Patients with Anorexia Nervosa) guideline, which provides paediatricians with a framework for managing Anorexia Nervosa in the inpatient setting.

[Child psychiatry: limited research, evidence for cost-effectiveness of treatment]. / Kinderpsychiatrie: beperkt onderzoek, aanwijzingen voor substantiële baten.

BACKGROUND: Research into cost-effectiveness of treatment of child psychiatric disorders is extremely limited. There are two main reasons for this: it's a new field and the type of research required is intrinsically complicated.
AIM: To review selected articles that reveal the prevalence of child psychiatric disorders, demonstrate the complexity of cost-efficiency research in child psychiatry and point to the possible benefits of appropriate treatment.
METHOD: We provide an overview of a selected number of articles dealing with the prevalence of child psychiatric disorders and the costs involved, we stress the diffulty of assessing whether current treatment is cost-effective and we describe the possible benefits of treatment.
RESULTS: However, the limited number of articles that we located do indicate that the treatment of children with psychiatric disorders is cost-effective. Not only does it benefit the child, it also eases the burden on the parents and on society as a whole. Findings need to be interpreted in the light of the limited scope and shortcomings of the research done so far.
CONCLUSION: Although current research seems to be cost-effective, we stress the need for further investigations, particularly in the form of longer-term studies.

[Structural quality in inpatient and daycare child and adolescent psychiatry- indicators for planning future staff ratios for the era following the Psychiatry Personnel Act]. / Strukturqualität in der stationären und teilstationären Kinder- und Jugendpsychiatrie.

The German Psychiatry Personnel Act, which went into effect in 1990, has led to a decrease in the number of child and adolescent psychiatry inpatient beds, to a decrease in the length of stay, and to an increase in inpatient psychotherapy. Today, this act is outdated~ for a number of reasons, such as changes in the morbidity of the population, the rising number of emergencies, and new professional standards such as documentation. In addition, new legal provisions and conventions (like the UN Convention on the Rights of the Child) necessitate a complete reevaluation. Child and adolescent psychiatry needs a normative act to enable the necessary implementation. Many different rationales are available to support the debate.

Women and Children Last: Reflections on the History of Child Psychoanalysis.

From the very first efforts to analyze children and adolescents to the present day, child and adolescent analysis has been denigrated in the analytic community. It has been viewed as "women's work" and regarded as clinically inferior to the analysis of adults. It has been seen as less important for understanding the psyche and in the training of psychoanalysts. This attitude is rationalized by observations that children and adolescents engage psychological material differently than adults do, so that, it is claimed, child and adolescent analysis is severely limited compared to adult analysis with regard to the material available for analysis. Beliefs that children require socialization lead some child analysts to indoctrinate children and sacrifice a respectful exploratory and uncovering approach. The situation of child analysis reflects larger social phenomenona, namely childism and sexism, the prejudices against children and women, as these prejudices are elaborated in our culture. Like others, child analysts respond to being the objects of prejudice by both isolating ourselves, reacting against the prejudice, and internalizing the prejudice. This paper includes clinical and institutional illustrations of these prejudices in action.

Editorial: Trials and tribulations in child psychology and psychiatry: what is needed for evidence-based practice.

If your child had leukaemia you would be distraught. Yet, there would also be hope. Most children with a diagnosis of leukaemia start their treatment as part of ongoing trials. The clinical teams looking after such children are motivated, knowledgeable and work in centres that specialise in the treatment of this lethal illness. The results speak for themselves. Not only have the trials helped oncologists learn more about which treatments work best. For years we have known that those who enter trials do better than those patients with similar characteristics who don't. We have recently also learnt that trials improve survival rates in those cancers population wide: the annual reduction between 1978-2005 in risk of death from childhood cancers ranged from 2.7% to 12.0%. This cancer trial culture is a splendid example of British health care delivery. What is happening in child psychiatry, though? If your child had, say, depression you would have every reason to be distraught too. The mortality rate is higher than in the general population and the burden of disease in the long run heavier than that of cardiovascular illness or cancer. Yet, your child would not have access to a trial. Instead, you would probably struggle to have your child's depression recognised in the first place. The care you would get would be determined by extreme regional variations and by what resources are available to local services and often the ideology or preferences of practitioners.