Moderators and predictors of outcomes in telephone delivered compared to face-to-face cognitive behaviour therapy for paediatric obsessive-compulsive disorder: preliminary evidence from a non-inferiority RCT.

This study provides a preliminary exploration of factors which differentially predict treatment response to telephone-delivered cognitive behavioural therapy (TCBT) compared to face-to-face CBT (CBT) in a randomised non-inferiority controlled trial of 72 children (aged 11-18 years) with obsessive-compulsive disorder (OCD). Potential moderator variables, their interaction with treatment group (CBT, TCBT) and baseline levels of OCD severity were entered into separate regression models where the primary outcome measure was the post-intervention Children's Yale-Brown Obsessive-Compulsive Scale total score (CYBOCS). Separate regressions were also used to test associations between predictors and outcome controlling for pretreatment CYBOCS. Only pretreatment level of parent-rated child peer problems moderated the effects of the two interventions on CYBOCS severity at post-treatment. After controlling for baseline CYBOCS, only family accommodation rated by mothers predicted poorer outcomes in both groups. While CBT and TCBT may be equally effective for adolescents with OCD, the current results tentatively suggest that higher baseline level of peer problems strengthened the response to therapy for youth receiving TCBT and the predictor analyses reinforce the importance of directly addressing family accommodation during CBT for paediatric OCD regardless of delivery mode. Limitations of the current findings and directions for future work are discussed.

Is childhood OCD a risk factor for eating disorders later in life? A longitudinal study.

BACKGROUND: It has been suggested that childhood obsessive-compulsive disorder (OCD) may be a risk factor for the development of an eating disorder (ED) later in life, but prospective studies are lacking. We aimed to determine the prevalence of ED at follow-up and clinical predictors in a longitudinal clinical sample of adolescents/young adults diagnosed with OCD in childhood. METHOD: All contactable (n=231) young people with OCD assessed over 9 years at a national and specialist paediatric OCD clinic were included in this study. At follow-up, 126 (57%) young people and parents completed the ED section of the Developmental and Well-being Assessment. Predictors for ED were investigated using logistic regression. RESULTS: In total, 16 participants (12.7%) had a diagnosis of ED at follow-up. Having an ED was associated with female gender and persistent OCD at follow-up. There was a trend for family history of ED being predictive of ED diagnosis. Five (30%) of those who developed an ED at follow-up had ED symptoms or food-related obsessions/compulsions at baseline. A difference in predictors for an ED versus other anxiety disorders at follow-up was identified. CONCLUSIONS: This study provides initial evidence that baseline clinical predictors such as female gender and family history of ED might be specific to the later development of ED in the context of childhood OCD. Clinicians should be alert to ED subthreshold symptoms in young girls presenting with OCD. Future longitudinal studies are needed to clarify the relationship between childhood OCD and later ED.

Long-term outcomes of obsessive-compulsive disorder: follow-up of 142 children and adolescents.

BACKGROUND: Obsessive-compulsive disorder (OCD) often starts in childhood and adolescence and can be a chronic disorder with high persistence rates. There are few prospective long-term follow-up studies. AIMS: To follow up young people with OCD to clarify persistence rates and relevant predictors, presence of other psychiatric disorders, functional impairment, service utilisation and perceived treatment needs. METHOD: All young people with OCD assessed over 9 years at the National and Specialist Paediatric OCD clinic, Maudsley Hospital, London, were included. Sixty-one per cent (142 of 222) of all contactable young people and parents completed computerised diagnostic interviews and questionnaires. RESULTS: We found a persistence rate of OCD of 41%; 40% of participants had a psychiatric diagnosis other than OCD at follow-up. The main predictor for persistent OCD was duration of illness at assessment. High levels of baseline psychopathology predicted other psychiatric disorders at follow-up. Functional impairment and quality of life were mildly to moderately affected. Approximately 50% of participants were still receiving treatment and about 50% felt a need for further treatment. CONCLUSIONS: This study confirms that paediatric OCD can be a chronic condition that persists into adulthood. Early recognition and treatment might prevent chronicity. Important challenges for services are ensuring adequate treatment and a smooth transition from child to adult services.

Brief psychological interventions for psychiatric disorders in young people with long term physical health conditions: A systematic review and meta-analysis.

OBJECTIVES: Rates of psychiatric disorders are considerably elevated in young people with long term physical health conditions. Currently few children obtain effective mental health treatments in the context of long term physical health conditions, and ways to improve access to evidence-based mental health interventions are urgently needed. One approach is to deploy briefer, more economical, yet still evidence-based, treatments. The objective of this review was to evaluate the efficacy of brief interventions targeting psychiatric disorders in children and young people with long term physical health conditions. METHODS: Predefined terms relating to brief psychological interventions for psychiatric disorders in children with long term physical health conditions were used to search relevant databases. A systematic review and meta-analysis was carried out in accordance with the Cochrane guidelines. Two reviewers independently screened titles and abstracts, extracted the data and conducted risk of bias assessments. RESULTS: A total of 12 randomised controlled trials were found to meet the inclusion criteria of the review. Of those, three studies were suitable for meta-analysis. A large effect size in favour of brief cognitive behavioural therapy for anxiety was found (g = - 0.95, CI -1.49 to -0.041; p < .001) with non-significant moderate-substantial heterogeneity (I2 = 58%; p = .09). CONCLUSION: This review suggests there is preliminary evidence that brief interventions, based on cognitive behavioural principles, may benefit young people with an anxiety disorder in the context of a long term physical health condition. There was insufficient evidence to assess whether this held true for depression and disruptive behaviour.

The quality of life of young people with Tourette syndrome.

BACKGROUND: The study examined a UK sample of 57 young people with Tourette syndrome (TS). AIMS: The purpose of this study was to consider the impact of TS on young people's Quality of Life (QoL). METHODS: The study used a mixed methods design, combining focus groups and questionnaire data. Child report questionnaires measured QoL and TS symptom severity. RESULTS: The results showed that the QoL of children with TS was significantly worse than that of children in a UK normative sample. Analysis of transcripts from the groups identified four main themes; 'TS can be distressing and disabling', 'struggling to fit into society's expectations of normal behaviour', 'needing to control tics' and 'TS is one part of who I am'. CONCLUSIONS: Poorer QoL was associated with increased symptom severity in terms of tics, Attention Deficit Hyperactivity Disorder diagnosis and obsessive compulsive behaviours.

Medically unexplained visual loss in children and young people: an observational single site study of incidence and outcomes.

PurposeTo determine the incidence of medically unexplained visual loss (MUVL) in children in an open access children's eye casualty.Patients and methodsWe collated demographic and clinical data of consecutive patients younger than 16 years who presented to the children's eye casualty at Moorfields Eye Hospital over a 12-month period and were diagnosed with MUVL or suspected MUVL. We reviewed the clinical records at least 3 months after initial presentation. We calculated the incidence using the number of 'new patient' attendances over the same period as denominator (n=2397). We used descriptive analysis. MAIN OUTCOME MEASURES: number of patients diagnosed with MUVL, proportion of patients with a history of or present psychological problems, recovery rate, and improvement in visual acuity.ResultsWe identified 85 cases of MUVL (54 females; median age: 9 years (IQR 7-12)). The median duration of follow-up was 1.2 months (IQR 0-4.3). The estimated annual incidence was 3.5% (95% confidence interval 2.9-4.4%). Thirty-three per cent of children had a history of psychiatric disorders, reported a stressful life event, or showed signs of psychiatric disorder at the time of first presentation. The recovery rate was 25%. Median improvement in best-corrected visual acuity from presentation to last appointment was 0.22 (IQR 0.06-0.43) logMAR.ConclusionThe incidence of MUVL is higher and the rate of resolution lower than previously reported. MUVL may be associated with mental health problems. We recommend screening for psychological problems to facilitate access to psychological treatment.

A review of psychiatric co-morbidity described in genetic and immune mediated movement disorders.

Psychiatric symptoms are an increasingly recognised feature of movement disorders. Recent identification of causative genes and autoantibodies has allowed detailed analysis of aetiologically homogenous subgroups, thereby enabling determination of the spectrum of psychiatric symptoms in these disorders. This review evaluates the incidence and type of psychiatric symptoms encountered in patients with movement disorders. A broad spectrum of psychiatric symptoms was identified across all subtypes of movement disorder, with depression, generalised anxiety disorder and obsessive-compulsive disorder being most common. Psychosis, schizophrenia and attention deficit hyperactivity disorder were also identified, with the psychiatric symptoms often predating onset of the motor disorder. The high incidence of psychiatric symptoms across such a wide range of movement disorders suggests a degree of common or overlapping pathogenic mechanisms. Our review demonstrates the need for increased clinical awareness of such co-morbidities, which should facilitate early neuropsychiatric intervention and allied specialist treatment for patients.

Electrocardiographic evolutionary changes and left ventricular remodeling after acute myocardial infarction: results of the GISSI-3 Echo substudy.

OBJECTIVES: The aim of this study was to describe the electrocardiographic (ECG) evolutionary changes after an acute myocardial infarction (AMI) and to evaluate their correlation with left ventricular function and remodeling. BACKGROUND: The QRS complex changes after AMI have been correlated with infarct size and left ventricular function. By contrast, the significance of T wave changes is controversial. METHODS: We studied 536 patients enrolled in the GISSI-3-Echo substudy who underwent ECG and echocardiographic studies at 24 to 48 h (S1), at hospital discharge (S2), at six weeks (S3) and six months (S4) after AMI. RESULTS: The number of Qwaves (nQ) and QRS quantitative score (QRSs) did not change over time. From S2 to S4, the number of negative T waves (nT NEG) decreased (p < 0.0001), wall motion abnormalities (%WMA) improved (p < 0.001), ventricular volumes increased (p < 0.0001) while ejection fraction remained stable. According to the T wave changes after hospital discharge, patients were divided into four groups: stable positive T waves (group 1, n = 35), patients who showed a decrease > or =1 in nT NEG (group 2, n = 361), patients with no change in nT NEG (group 3, n = 64) and those with an increase > or =1 in nT NEG (group 4, n = 76). The QRSs and nQ remained stable in all groups. Groups 3 and 4 showed less recovery in %WMA, more pronounced ventricular enlargement and progressive decline in ejection fraction than groups 1 and 2 (interaction time x groups p < 0.0001). CONCLUSIONS: The analysis of serial ECG can predict postinfarct left ventricular remodeling. Normalization of negative T waves during the follow-up appears more strictly related to recovery of regional dysfunction than QRS changes. Lack of resolution and late appearance of new negative T predict unfavorable remodeling with progressive deterioration of ventricular function.

Transformation obsessions in paediatric obsessive-compulsive disorder: Clinical characteristics and treatment response to cognitive behaviour therapy.

BACKGROUND AND OBJECTIVES: Transformation obsessions denote an under-reported symptom of Obsessive Compulsive Disorder (OCD), characterised by an excessive fear of turning into another person/object or acquiring unwanted characteristics. Relative to other OCD symptoms, little is known about the clinical presentation of transformation obsessions. The study aims to examine the clinical correlates and treatment prognosis of transformation obsessions in a paediatric OCD sample. METHODS: The sample consisted of 346 youths with a primary diagnosis of OCD. Patients with and without transformation obsessions were compared in terms of demographic and clinical characteristics, and CBT outcomes. RESULTS: 10% of the sample endorsed transformation obsessions. Patients with transformation obsessions were more likely to be boys, to be on augmented medication regimes, and to present with more severe obsessions at assessment. A factor analysis identified four major OCD symptom clusters, with transformation obsessions loading on a 'forbidden thoughts' factor alongside aggressive, sexual, and religious obsessions. No group differences in treatment outcomes were observed. LIMITATIONS: Limitations include the cross-sectional and retrospective nature of the study, the representativeness of our sample, and use of concomitant medication, among others. CONCLUSIONS: The study provides the first empirical evidence regarding phenomenological similarities and differences between paediatric OCD patients presenting with and without transformation obsessions. The findings suggest that transformation obsessions are best conceptualised as related to 'forbidden' obsessions and respond to exposure-based CBT.

Paediatric Obsessive-Compulsive Disorder and Depressive Symptoms: Clinical Correlates and CBT Treatment Outcomes.

Depression frequently co-occurs with paediatric obsessive-compulsive disorder (OCD), yet the clinical correlates and impact of depression on CBT outcomes remain unclear. The prevalence and clinical correlates of depression were examined in a paediatric specialist OCD-clinic sample (N = 295; Mean = 15 [7 - 18] years, 42 % female), using both dimensional (Beck Depression Inventory-youth; n = 261) and diagnostic (Development and Wellbeing Assessment; n = 127) measures of depression. The impact of depressive symptoms and suspected disorders on post-treatment OCD severity was examined in a sub-sample who received CBT, with or without SSRI medication (N = 100). Fifty-one per-cent of patients reported moderately or extremely elevated depressive symptoms and 26 % (95 % CI: 18 - 34) met criteria for a suspected depressive disorder. Depressive symptoms and depressive disorders were associated with worse OCD symptom severity and global functioning prior to CBT. Individuals with depression were more likely to be female, have had a psychiatric inpatient admission and less likely to be attending school (ps < 0.01). OCD and depressive symptom severity significantly decreased after CBT. Depressive symptoms and depressive disorders predicted worse post-treatment OCD severity (ßs = 0.19 and 0.26, ps < 0.05) but became non-significant when controlling for pre-treatment OCD severity (ßs = 0.05 and 0.13, ns). Depression is common in paediatric OCD and is associated with more severe OCD and poorer functioning. However, depression severity decreases over the course of CBT for OCD and is not independently associated with worse outcomes, supporting the recommendation for treatment as usual in the presence of depressive symptoms.

Does 1,25-dihydroxyvitamin D participate in the regulation of hormone release from endocrine glands?

The presence of receptors for 1,25-dihydroxyvitamin D3 in the pituitary, pancreas, testis, and ovary has raised the question of a possible direct role for 1,25-dihydroxyvitamin D (1,25(OH)2D) in the regulation of hormone synthesis and secretion. To evaluate this problem, six children with the syndrome of resistance to 1,25(OH)2D with rickets and alopecia underwent dynamic tests of insulin, TSH, PRL, GH, and testosterone secretion. Oral glucose loading resulted in normal glucose curves, subnormal peak insulin responses of 12-20 microU/ml in three hypocalcemic patients, and normal peak serum insulin values of 30-40 microU/ml in two normocalcemic patients. Basal serum, TSH, PRL, T4, and T3 concentrations were normal in all patients. Peak serum TSH values after TRH were 11-17 and 16-32 microU/ml in the hypo- and normocalcemic patients, respectively. The PRL response to TRH stimulation in either hypocalcemic or normocalcemic patients was normal [mean 26.2 +/- 5.1 (SD) ng/ml]. Peak serum GH levels were greater than 8 ng/ml in all five patients studied after one or more of the various stimuli. Serum testosterone concentrations after hCG stimulation were normal in the three patients studied (4.1-8.0 ng/ml). Thus, in children with resistance to 1,25(OH)2D, we could find no significant abnormalities in hormone secretion from the pituitary, pancreas, and testis apart from those presumably due to the hypocalcemia itself.

Psychiatric disorder and cognitive function in a family with an inherited novel mutation of the developmental control gene PAX6.

The PAX family of developmental control genes are known to play important roles in the early patterning of the central nervous system. One member of this family, PAX6, is involved in eye development in invertebrates as well as in mouse and man, but is also widely expressed in the developing forebrain. Humans with a mutation in this gene have abnormalities of eye development, and the results presented here suggest, for the first time, that this mutation may also be associated with subtle abnormalities of frontal lobe function in the family studied. We carried out genotyping of individuals within a single family, with and without the characteristic eye abnormalities of PAX6 mutation, and only those individuals with the mutation showed significant abnormalities on tests of frontal lobe function. These individuals also had higher rates of psychiatric disorder. PAX6 is highly conserved between mouse and man, and although the neuroanatomical phenotype associated with PAX6 heterozygosity has only been studied in mice, the resultant cellular disorganization seen in mice is likely to be present in the human forebrain. Although these mice have no obvious behavioural phenotype, the results presented here suggest that humans with the equivalent mutation display a neurobehavioural phenotype.

Depolarizing responses to capsaicin in a subpopulation of rat dorsal root ganglion cells.

Microelectrode recordings from the somata of rat dorsal root ganglion (DRG) cells were used to correlate their electrophysiological characteristics with sensitivity to locally applied capsaicin. Of the 80 cells tested, 17 responded to capsaicin by a rapid depolarization. These cells had low axonal conduction velocities (less than 1.4 m/s) and long duration action potentials, characteristic of C-cells. Some C-cells did not respond to capsaicin, and no A-cells, which had high conduction velocities and brief action potentials, did so. The effect of capsaicin on the current-voltage curve of C-cells suggested that it produced a conductance increase as well as a change in delayed rectification.

Cetaben versus clofibrate: comparison of toxicity and peroxisome proliferation in rats.

Cetaben and clofibrate were each administered to groups of 6 rats (3 male and 3 female) by gavage at dosages of 50 mg/kg per day and 200 mg/kg per day for 2 weeks. Cetaben caused 1 death at 200 mg/kg per day and decreases in body weight gain and food consumption at 50 mg/kg per day or more. There were no effects on body weight or food consumption in the clofibrate-treated groups. At 200 mg/kg per day cetaben and clofibrate induced comparable increases in liver weight and in numbers of liver peroxisomes while cetaben caused increases in liver catalase activity as well.

Psychopathology in children with epilepsy before and after temporal lobe resection.

The aim of this study was to establish the rate and spectrum of psychiatric disorder among children before and after temporal lobe surgery for epilepsy. Data were examined for associations between psychopathology and seizure outcome following surgery, or association between psychopathology and other variables, such as laterality of lesion, sex, cognitive level, and underlying pathology. Participants were 60 children (35 males, 25 females) who had focal seizures of temporal lobe origin and who had undergone temporal lobe resection between 1992 and 1998; mean age at time of operation 10 y 7 mo, (SD 4 y 11 mo) range 7 mo to 17 y 11 mo. Mean length of follow-up was 5.1 years (SD 2.3, range 2 to 10 y). Twenty-eight (47%) children had undergone right temporal lobectomy. Diagnosis of a psychiatric disorder was present in 50/60 (83%) children at some point, with high rates of psychiatric comorbidity. Common childhood psychiatric disorders of attention-deficit-hyperactivity disorder, oppositional defiant disorder/conduct disorder, and emotional disorders were present in about 25% of children. Disorders rarely seen in the general child population were over-represented: disruptive behaviour disorder--not otherwise specified (30/60 [50%]), and pervasive developmental disorder (autistic spectrum disorder; 23/60 [38%]). there was no significant relationship between pathology, sex, seizure frequency, or postoperative seizure outcome and psychiatric disorder, other than for pervasive developmental disorder. The same proportion of children had psychiatric diagnoses pre- and postoperatively (43/60 [72%] and 41/57 [72%] respectively). Although mental health problems are common in children undergoing temporal lobe resection, there are few predictors of psychiatric outcome following epilepsy surgery. Parents require counselling on these issues in the preoperative work-up.

Different paradigms in a new research domain. The case of nursing research on diabetes in Sweden.

The aim of this study was to examine doctoral theses written by nurses on the same subject, namely diabetes. The five theses were published during three years. The text analysis emphasized the purposes, theoretical framing, methods for collection and analyzing the data, ways of presenting the texts and, finally, the references in the five theses. The findings indicate that the authors make use of different paradigms. Experimental approach was used in some theses and one thesis was based on grounded theory. Two theses could be said to be more concise that the others because they made use of only one technique each--physiological measurements and an open-ended interview. The remainder used of a number of methods--in other words, they were eclectic in approach. The conclusion is that there is a freedom for nurse researcher to affiliate to different scientific traditions inside academia--the two in question here are biomedical research and interpretative traditions inside social science. The author encourage all researchers inside the nursing domain to subject herself to criticism and reflection to the same extent as she analyzes other people or phenomena in order to increase epistemological awareness of the use of research tools, perspectives and theories.

The work of practical nursing educators. A case study report.

In 1987 a study was carried out at two upper secondary schools. The aim was to study the working conditions of teachers in a changing environment by interviewing different professionals in the school as well as students. In the last five years, the average age of students was found to have fallen by two to four years. Another finding was that the entrance requirements had been lowered. In the same five-year period the drop-out rates at one of the two schools had risen from 5/60 to 18/81. At the other school 5/30 dropped out in 1987. Many of the teachers interviewed reported their students to be open-minded and spontaneous but at the same time too immature to work in the medicare sector, especially in the psychiatric field. A tendency appeared for teachers to take on a more curative and supportive role. The teachers maintained certain minimum standards and students who did not pass their examinations were required to withdraw.