WAIMH position paper: Infants' rights in wartime.

The World Association for Infant Mental Health (WAIMH) decided to compose a position paper on infants' rights in wartime, as there is still a general lack of attention paid to the impact of war-related traumas on infants' development and psychological health. Though there are numerous areas of violent conflicts around the globe, there have been few published studies that relate specifically to infants. Consequently, humanitarian aid programs tend to overlook infants' psychological needs and to pay more attention to those of older children. This position paper first reviews the studies identified through a literature search, about the impact of war-related traumas during pregnancy and postnatal periods, then describes the existing recommendations that have been added to the Children Rights Convention and their implications for infant mental health clinicians.

A controlled trial of implementing a complex mental health intervention for carers of vulnerable young people living in out-of-home care: the ripple project.

BACKGROUND: Out-of-home care (OoHC) refers to young people removed from their families by the state because of abuse, neglect or other adversities. Many of the young people experience poor mental health and social function before, during and after leaving care. Rigorously evaluated interventions are urgently required. This publication describes the protocol for the Ripple project and notes early findings from a controlled trial demonstrating the feasibility of the work. The Ripple project is implementing and evaluating a complex mental health intervention that aims to strengthen the therapeutic capacities of carers and case managers of young people (12-17 years) in OoHC. METHODS: The study is conducted in partnership with mental health, substance abuse and social services in Melbourne, with young people as participants. It has three parts: 1. Needs assessment and implementation of a complex mental health intervention; 2. A 3-year controlled trial of the mental health, social and economic outcomes; and 3. Nested process evaluation of the intervention. RESULTS: Early findings characterising the young people, their carers and case managers and implementing the intervention are available. The trial Wave 1 includes interviews with 176 young people, 52% of those eligible in the study population, 104 carers and 79 case managers. CONCLUSIONS: Implementing and researching an affordable service system intervention appears feasible and likely to be applicable in other places and countries. Success of the intervention will potentially contribute to reducing mental ill-health among these young people, including suicide attempts, self-harm and substance abuse, as well as reducing homelessness, social isolation and contact with the criminal justice system. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry ACTRN12615000501549 . Retrospectively registered 19 May 2015.

Diffusion of efficacious interventions for children and adolescents with mental health problems.

BACKGROUND: Child and adolescent mental health problems are prevalent and require adequate interventions. Despite several evidence-based interventions for these problems described in the literature, few studies addressed strategies to diffuse efficacious interventions for child mental disorders especially in developing countries. METHODS: An extensive but not systematic review of the literature was performed aiming to identify evidence-based interventions for children and adolescents with mental disorders, professionals to target in disseminating these interventions, and the available strategies to diffuse information. RESULTS: Substantial evidence-based information is available to guide preventive, psychosocial and psychopharmacological interventions. The effectiveness of treatments in real-world settings and the cost-effectiveness of interventions are rarely tested. Professionals at different levels (teachers, school counselors, social workers, general practitioners, pediatricians, child psychologists and psychiatrists) should be targeted in diffusing efficacious interventions for child mental health problems worldwide. Telepsychiatry and the internet seem to be the most promising strategies to diffuse knowledge with lower costs. CONCLUSIONS: Medical and allied professionals must incorporate child and adolescent mental health issues in their under- and postgraduate curricula, and be better prepared to critically evaluate available information. Professionals need to disseminate evidence-based programs to guide parents and teachers in developing countries to deal with child and adolescent difficulties. Countries need to explore internet solutions for dissemination of medical information.

Objective versus subjective assessment of methylphenidate response.

Subjective improvement-assessment in attention deficit/hyperactivity disorder (ADHD), following a single dose of methylphenidate (MPH) was compared to performance on the Test-of-Variables-of-Attention (TOVA). Self-perception was assessed with the clinical-global-impression-of-change (CGI-C). Participants included 165 ADHD subjects (M:F ratio 67%:33%) aged 5-18 (11.09 +/- 3.43) years. TOVA was administered before and after MPH challenge (0.3 mg/kg). Self-perception CGI-C scores were compared to the TOVA scores. An inverse correlation was found only between CGI-C and the TOVA-Commission-scores (r = -0.326, p < 0.001). We thus conclude that subjective reports are too unreliable to be used in order to assess MPH benefit in ADHD pediatric populations.

Association between tryptophan hydroxylase 2, performance on a continuance performance test and response to methylphenidate in ADHD participants.

The main objective of this study was to examine neuropsychological mechanisms mediating the association between tryptophan hydroxylase 2 (TPH2) and attention deficit hyperactivity disorder (ADHD). A continuous performance test (T.O.V.A.) was administered to 344 participants diagnosed with DSM IV ADHD who were also genotyped for eight TPH2 intronic SNPs. Association between TPH2 (single SNPs and haplotypes), ADHD, and performance on the T.O.V.A. were tested using robust family-based association tests as implemented in two statistical genetic programs: UNPHASED and PBAT. Association was only observed between an eight locus haplotype and ADHD DSM IV combined type III (global P = 0.036). Robust association was observed between TPH2 single SNPs (and haplotypes) and performance on the T.O.V.A., especially Errors of Omission (eight locus haplotypes, global P = 0.038). Significant associations were also observed between TPH2 and improvement (before-after scores) in T.O.V.A. Total Response Variability scores following acute methylphenidate challenge (eight locus haplotypes, global P = 0.009). Using the MFBAT program, significant multivariate association was observed between single SNPs and haplotypes [eight locus haplotypes and all four T.O.V.A. variables (PBAT-GEE P = 0.013)]. The two most common TPH2 eight locus haplotypes were in a Yin Yang configuration and the Yang haplotype was the risk haplotype for both DSM IV ADHD and deficits in neuropsychological performance. The current investigation shows that risk for ADHD conferred by TPH2 variants is partially mediated by serotonergic mechanisms impacting some facets of executive function. Importantly, improvement in T.O.V.A. performance, especially on Response Time Variability, following methylphenidate was also associated with TPH2.

Depression in infancy.

The evolution of the concept of depression in infancy (0-3 years) is relatively new and follows a path similar to the history of depression in adolescence, then in childhood, and in preschool years. It started with Spitz observation of a depressive clinical syndrome, named anaclitic depression, followed by Bowlby's description of three phases in the development of infants who have been separated from their caregiver. Kreisler linked life-threatening feeding disorders with depression in infancy. This article reviews the different causes of depression in infancy. Clinical vignettes illustrate some of them. The main unanswered question is whether depression in infancy can be primary. Diagnostic criteria, differential diagnoses and prognoses are reviewed, as well as therapeutic concerns specific to infancy.

Follow-up of preschool children with severe emotional and behavioral symptoms.

BACKGROUND: Biological and environmental factors have been related to the persistence of psychopathology in preschool children. The objective of the study was to identify the factors predicting the clinical outcome in preschool inpatients with emotional and behavioral disorders. METHOD: Twenty-eight children aged 3 to 6.5 years attending a therapeutic nursery were evaluated. Clinical data were collected from the children's charts, including: biological parameters, developmental milestones, intelligence level, socioeconomic status, and stressful life events. Severity of symptoms at follow-up was assessed using the Clinical Global Impression Scale. RESULTS: Low socioeconomic status, excess stressful life events, and female gender were associated with poor clinical outcome. Biological factors such as pregnancy and birth complications and genetic factors were not significant predictors. LIMITATIONS: The study was limited by its retrospective design and small sample size. CONCLUSIONS: More effort in social interventions and supportive family therapy may improve the outcome of young children with emotional and behavioral problems.

Family-based association study of 5-HT(2A) receptor T102C polymorphism and suicidal behavior in Ashkenazi inpatient adolescents.

UNLABELLED: Suicidal behavior runs in families and is partially genetically determined. Since greater serotonin 5-HT(2A) receptor binding has been reported in postmortem brain and platelets of suicide victims, the 5-HT(2A) receptor gene polymorphism T102C became one of the candidate sites in the study of suicide and impulsive-aggressive traits. However, studies that examined the association of this polymorphism with suicidality have contradictory results. This study used a family-based method and one homogenous ethnic group to overcome ethnic stratification in order to test this association. METHODS: Thirty families of inpatient adolescents from Jewish Ashkenazi origin, with a recent suicide attempt, were genotyped. All subjects were interviewed for clinical diagnosis, depressive and impulsive-aggressive traits and demographic data. Allele frequencies were assessed using the Haplotype Relative Risk method for trios. RESULTS: No difference was found in allelic distribution between transmitted and non-transmitted alleles. There was no significant association of genotype with any of the clinical traits CONCLUSIONS: These preliminary results suggest that the 5-HT(2A) T102C polymorphism is unlikely to be associated with suicidal behavior and related traits in adolescent suicide attempters.

[The difficult child syndrome].

Many children are referred to the psychiatrist with the title of the "difficult child". Behind that popular and nonscientific description hide several major psychiatric syndromes, such as attention-deficit hyperactivity disorder, disruptive behavior disorders, mood disorders and posttraumatic stress disorder. This article reviews the different clinical faces of these disorders, their differential diagnoses, comorbidity and prognosis. These disorders are very prevalent and have long-term consequences on the process of development of the child. Acquaintance with the disorders, early diagnosis and treatment can prevent complications and improve the prognosis.

Psychopathology and its Early Impact on Parenting Behaviors in Mothers: The Interface between Adult and Infant Psychiatry.

Parenting is, in its essence, the domain where adult mental health and infant's mental and physical health meet in a complex and dynamic interplay. Becoming a parent is a developmental challenge in itself, and often exacerbates an existing mental illness, and in turn, maladaptive parenting impinges on the early parent-infant relationship, and on the infant's socio-emotional development and later functioning. The capacity for mentalization is brought as a bridging concept between adult and infant psychiatry. A few clinical vignettes illustrate the dynamic interplay between very young children's vulnerabilities and needs and their parents' strengths and weaknesses, leading to a complex interaction and often to symptoms in both child and parent. In the light of the compelling data about the impact of parental psychopathology on parenting behaviors and children outcomes, there is an imperative need for a working alliance and on-going communication between child and adult psychiatrists.

The Outcome of Severe Internalizing and Disruptive Disorders from Preschool into Adolescence:A Follow-up Study.

PURPOSE: In this study we aimed to examine the outcome of children's severe psychiatric disorders from preschool into later childhood and adolescence. METHOD: Forty preschool children (28 boys and 12 girls) treated in a tertiary referral mental health center, evaluated at admission and 5.5 ± 1.2 years thereafter. RESULTS: Seven (58.3%) children diagnosed with internalizing disorders at baseline were free of any psychiatric diagnosis at follow-up (p=0.02). Conversely, only one child (8.3%) diagnosed with comorbid disruptive-internalizing disorders at baseline was free of any psychiatric disorder at follow-up (p=1.0). Seven (43.7%) children diagnosed with disruptive disorders at baseline were free of psychiatric diagnoses at follow-up (p=0.02). LIMITATIONS: The small sample size and naturalistic nature of the study. CONCLUSION: The trajectories of severe psychiatric disorders at preschool years are similar to those reported in community samples and differ according to the baseline diagnosis. Children with internalizing disorders show a much better recovery rate than those with comorbid disruptive and internalizing disorders.

Mother-Child touch patterns in infant feeding disorders: relation to maternal, child, and environmental factors.

OBJECTIVE: To examine mother and child's touch patterns in infant feeding disorders within a transactional framework. METHOD: Infants (aged 9-34 months) referred to a community-based clinic were diagnosed with feeding disorders (n = 20) or other primary disorder (n = 27) and were case matched with nonreferred controls (n = 47). Mother-child play and feeding were observed and the home environment was assessed. Microcoding detected touch patterns, response to partner's touch, and proximity at play. Relational behaviors were coded during feeding. RESULTS: Compared with infants with other primary disorder and case-matched controls, less maternal affectionate, proprioceptive, and unintentional touch was observed in those with feeding disorders. Children with feeding disorders displayed less affectionate touch, more negative touch, and more rejection of the mother's touch. More practical and rejecting maternal responses to the child's touch were observed, and children were positioned more often out of reach of the mothers' arms. Children with feeding disorders exhibited more withdrawal during feeding and the home environment was less optimal. Feeding efficacy was predicted by mother-child touch, reduced maternal depression and intrusiveness, easy infant temperament, and less child withdrawal, controlling for group membership. CONCLUSIONS: Proximity and touch are especially disturbed in feeding disorders, suggesting fundamental relationship difficulties. Mothers provide less touch that supports growth, and children demonstrate signs of touch aversion. Touch patterns may serve as risk indicators of potential growth failure.

International consensus statement on attention-deficit/hyperactivity disorder (ADHD) and disruptive behaviour disorders (DBDs): clinical implications and treatment practice suggestions.

Researchers and clinicians worldwide share concerns that many youngsters with attention-deficit/hyperactivity disorder (ADHD) and/or disruptive behaviour disorders (DBDs) do not receive appropriate treatment despite availability of effective therapies. At the request of Johnson and Johnson (sponsor), 11 international experts in child and adolescent psychiatry were selected by Professor Stan Kutcher (chair) to address these concerns. This paper describes the experts' consensus conclusions, including treatment practice suggestions for physicians involved in the early treatment of youngsters with ADHD (or hyperkinetic disorder, in countries preferring this classification) and/or DBDs internationally: suggested first-line treatment for ADHD without comorbidity is psychostimulant medication aided by psychosocial intervention. For ADHD with comorbid conduct disorder (CD), psychosocial intervention combined with pharmacotherapy is suggested. For primary CD, suggested first-line treatment is psychosocial intervention, with pharmacotherapy considered as an 'add-on' when aggression/impulsivity is marked and persistent. Pharmacotherapy requires careful titration; full-day coverage is the suggested goal. Regular long-term follow-up is recommended.

Olanzapine treatment in chronic drug-resistant childhood-onset schizophrenia: an open-label study.

The use of typical antipsychotics is limited in children with schizophrenia, owing to the high rate of response failure and early appearance of extrapyramidal syndromes as well as tardive and withdrawal dyskinesia. The aim of the present study was to examine the effectiveness of the atypical antipsychotic olanzapine in the treatment of childhood-onset schizophrenia. The study sample included nine children hospitalized for schizophrenia who had proven refractory to treatment with at least two antipsychotic drugs. Olanzapine was administered after a 2-week washout period in gradually increasing doses to a maximum of 5 mg/day on day 5 and 10 mg/day in week 3; six patients received up to 20 mg/day as of week 5. The duration of the study was 12 weeks. Patient psychiatric status was measured with three scales at onset of therapy and thereafter once weekly. Patients also underwent regular blood, laboratory, and liver function tests, and we also monitored their blood pressure and weight and performed electrocardiography and electroencephalography. A reduction in all psychopathology scores was obtained at 12 weeks from baseline. All extrapyramidal symptoms of previous medications resolved, and there were no new incidents. Side effects were mild. There were no adverse changes in blood chemistry, hematological tests, or electrocardiography parameters, but the treatment was associated with a significant weight gain (6.10 +/- 3.25 kg). At 1-year follow-up, the improvement in psychiatric symptoms was sustained in eight children. We conclude that olanzapine may have potential as a first-line drug in the treatment of drug-resistant childhood-onset schizophrenia. Large-scale, double-blind, placebo-controlled comparative studies are needed to clarify the role of the various atypical antipsychotics in both treatment-resistant and treatment-naïve populations with psychotic symptoms/disorders.

The wish to die and the wish to commit suicide in the adolescent: two different matters?

We shall try to demonstrate the difference between two wishes--the wish to die and the wish to commit suicide--as they express themselves during adolescence. First, death is seen as irreversible, while the suicidal act, at least during adolescence, is seen as reversible. While thoughts of suicide may be a part of normal adolescence, and the suicidal act a manifestation of pathological development specific to this stage in life, the wish to die has no age restrictions and may accompany life as a shadow, devoid of any suicidal act, for many years. It should be noted that both of these wishes may be balanced with the wish to live. Pathology appears when there is an imbalance of wishes and abnormal developmental processes. This imbalance can result in two distinct activities: suicidal acts and death behaviors. We suggest that the two stem from different mechanisms and personality pathologies. Therefore, they should be evaluated separately in order to better understand differences between suicidal and other aggressive acts and manifestations of the death wish during adolescence.

Schizophrenia in adolescent twins: a case study.

Studies of schizophrenia in twins have historically influenced the psychiatric world in shifting the focus of the etiology of psychiatric disorders from a psychodynamic to a genetic one. Although twinning is as frequent a phenomenon as schizophrenia, clinical issues relating to the development of twins and treatment of psychiatrically sick twins are relatively infrequent in the literature. This article presents the treatment of adolescent schizophrenic twins, and focuses on specific developmental, educational and therapeutic issues that must be considered when treating twins. The recent treatment of identical schizophrenic twins has allowed us to review the literature and revisit some of these issues.

[The application of the patients' rights law in psychiatry].

The application of the Israeli law of patients rights in psychiatry raises several dilemmas. These dilemmas include the competence of a psychotic patient to consent to psychiatric hospitalization and the difficulties of sharing information concerning the psychiatric patient with the family although they are essential partners in the rehabilitation process. Another major problem is the loss of confidentiality of minor patients by the parents (or guardians) rights to examine their medical documentation. These issues have detrimental implications on the diagnosis and therapeutic process.

Partnerships for better mental health worldwide: WPA recommendations on best practices in working with service users and family carers.

WPA President M. Maj established the Task Force on Best Practice in Working with Service Users and Carers in 2008, chaired by H. Herrman. The Task Force had the remit to create recommendations for the international mental health community on how to develop successful partnership working. The work began with a review of literature on service user and carer involvement and partnership. This set out a range of considerations for good practice, including choice of appropriate terminology, clarifying the partnership process and identifying and reducing barriers to partnership working. Based on the literature review and on the shared knowledge in the Task Force, a set of ten recommendations for good practice was developed. These recommendations were the basis for a worldwide consultation of stakeholders with expertise as service users, families and carers, and the WPA Board and Council. The results showed a strong consensus across the international mental health community on the ten recommendations, with the strongest agreement coming from service users and carers. This general consensus gives a basis for Task Force plans to seek support for activities to promote shared work worldwide to identify best practice examples and create a resource to assist others to begin successful collaboration.

ADHD, temperament, and parental style as predictors of the child's attachment patterns.

This study investigates the impact of temperament and parenting styles on attachment patterns in children with ADHD. The study included 65 children aged 7-15 and their parents. Children diagnosed as Combined or Predominantly Hyperactive Impulsive Type had significantly higher scores than those diagnosed as Predominantly Inattentive Type in anxious and avoidant attachment, emotionality, and activity dimensions of temperament, and their parents reported higher levels of controlling styles. Hierarchic regressions indicated that parental promotion of autonomy with children with temperamental emotionality predicted anxious attachment, while parental restriction of autonomy with children with high levels of temperamental activity predicted avoidant attachment.