Emergency psychiatric care for children and adolescents: a literature review.

OBJECTIVES: Over the years, increasing numbers of children and adolescents have sought help for acute psychiatric problems. The responses to this treatment-seeking behavior are heterogeneous in different settings and nations. This review aimed to provide an answer to the questions "which care should be offered to children and adolescents presenting with a psychiatric emergency or crisis and how should it be organized." METHODS: We committed a literature review to find out if any recommendations can be made regarding the organization of emergency care for children and adolescents with acute mental health problems. RESULTS: The lack of a clear definition of emergencies or urgencies hampered this review; we note the differences between adult and child or adolescent psychiatry. The theoretical models of care found in the literature are built up from several process and structural components, which we describe in greater detail. Furthermore, we review the main service delivery models that exist for children and adolescents. CONCLUSIONS: Currently, emergency psychiatric care for children and adolescents is practiced within a wide range of care models. There is no consensus on recommended care or recommended setting for this population. More research is needed to make exact recommendations on the standardization of psychiatric care for young people in emergency settings.

Time-of-day effects in arousal: disrupted diurnal cortisol profiles in children with ADHD.

BACKGROUND: Fluctuations in attention-deficit hyperactivity disorder (ADHD) symptoms related to regulatory deficits in arousal states are themselves characterized by circadian rhythms. Although cortisol is an important circadian arousal-related marker, studies focusing on across-the-day cortisol variations in ADHD are scarce. There is no study with multiple measurements to take into account interday and intraday variability. METHODS: Salivary cortisol was sampled five times a day (awakening, 30 min after awakening, noon, 4 p.m., 8 p.m.) across five consecutive days in 33 children with ADHD (22 with and 11 without oppositional defiant disorder; ODD) and 33 class- and sex-matched controls (aged 6-12). The cortisol awakening response (increase from awakening to 30 min after awakening) and the diurnal cortisol profile (across-the-day variations) were compared for ADHD with ODD (ADHD + ODD) and without ODD (ADHD) subgroups and the control group. RESULTS: The cortisol awakening response was not significantly different between groups. However, longitudinal analyses to evaluate cortisol profiles across the day revealed a significant Group × Time effect (p < .001). More specifically, compared to each other, the ADHD subgroup showed a flatter slope with relative morning hypo-arousal and evening hyperarousal, whereas the ADHD + ODD subgroup showed a steeper slope with relative morning hyperarousal and evening hypo-arousal (p < .001). CONCLUSIONS: Findings support time-related arousal disruptions in children with ADHD associated with the presence or absence of ODD comorbidity. We recommend research on cortisol in larger samples for a better understanding of arousal mechanisms involved in ADHD not only with and without ODD but also with other comorbidities which may have implications for timing of arousal-based treatments.

The traumatic impact of motor vehicle accidents in high school students.

OBJECTIVES: To obtain the year prevalence of nonfatal motor vehicle accidents (MVAs) in adolescents, to describe trauma symptoms (posttraumatic stress, depression, anxiety, dissociation), and to test a theoretical model of traumatic events. METHODS: A community-based sample of 3,007 adolescents (mean age: 14.6 years) completed questionnaires regarding MVAs, appraisals, coping, support, and trauma symptoms. RESULTS: Three percent of the adolescents reported being injured in a MVA during the past year. Of the adolescents who reported a MVA in their life (22.4%), 11.0% reported significant posttraumatic stress or other trauma symptoms. Structural equation modeling revealed that negative appraisals mediated the relation between trauma symptoms and MVA severity. Avoidant coping partially mediated the relation between appraisal and trauma symptoms. Social support was associated with less negative appraisals and with more avoidant coping. CONCLUSIONS: Results suggest the need for a better registration of young traffic victims to optimize screening for psychological problems.

Differences in posttraumatic stress reactions between witnesses and direct victims of motor vehicle accidents.

The present study describes posttraumatic stress reactions in young witnesses of motor vehicle accidents (MVAs). This study investigated (a) whether witnesses of MVAs report fewer trauma symptoms than direct victims, but more than adolescents who were never exposed to an MVA; and (b) whether individual differences in sex, negative appraisal, avoidant coping, and social support account for variability in trauma symptoms beyond status as a witness as compared to a victim. Self-report data came from a community-based sample of 3,007 adolescents with an average age of 14.6 years and comprising 53% boys. Compared to direct victims of an MVA in which someone was injured, witnesses of MVAs with injury reported significantly less internalizing symptoms, such as symptoms of posttraumatic stress (d = 0.25), fear (d = 0.21), and depression (d = 0.17). Compared to adolescents who were never exposed to an MVA with injury, witnesses reported significantly more externalizing symptoms (d = 0.24). In multiple regression analyses the significant difference between witnesses and victims disappeared when sex, other stressful events, appraisals, and coping were added to the model. These findings suggest that adolescent witnesses, as well as direct victims, may be at risk for posttraumatic reactions.

Diurnal variations in arousal: a naturalistic heart rate study in children with ADHD.

Previous studies suggest an altered circadian regulation of arousal in children with attention-deficit hyperactivity disorder (ADHD) as measured by activity, circadian preference, and sleep-wake patterns. Although heart rate is an important measure to evaluate arousal profiles, to date it is unknown whether 24-h heart rate patterns differentiate between children with and without ADHD. In this study, 24-h heart rate data were collected in 30 non-medicated children with ADHD (aged 6-11) and 30 sex-, class-, and age-matched normal controls in their naturalistic home and school setting, during 5 days. Simultaneously, 24-h activity patterns were registered. Confounding effects of demographic variables (e.g., age, sex, BMI, pubertal stage) and comorbid internalizing and externalizing problems on heart rate levels were additionally assessed. Longitudinal analysis showed that heart rate levels were overall higher in the ADHD group (p < 0.01)--with the largest effects during afternoon and night--in a model controlling for age. Other factors did not significantly contribute to variations in heart rate levels. Compared to controls, children with ADHD showed higher activity levels during daytime (especially early afternoon), but not during nighttime (p < 0.05). Post hoc analyses showed that environmental effects might influence daytime variations. Findings suggest an autonomic imbalance in children with ADHD as compared to controls, with higher heart rate levels in the ADHD group. Nighttime tachycardia in this group could not be explained by nighttime activity levels or comorbid externalizing/internalizing problems. Further research on autonomic functioning in ADHD is recommended because of the major impact of higher resting heart rate on health outcomes.

Associations between common arginine vasopressin 1b receptor and glucocorticoid receptor gene variants and HPA axis responses to psychosocial stress in a child psychiatric population.

On the one hand, a suitable response to daily stressors is crucial for adequate functioning in any natural environment. On the other hand, depending on the individual's genetic makeup, prolonged stress that is accompanied by an inappropriate level of responsiveness may lead to physiological and psychiatric disorders. Several psychiatric conditions have been linked with stress and alterations in hypothalamic-pituitary-adrenal (HPA) activity. While stress is a general phenomenon, illness is only seen in a proportion of individuals, suggesting that genetic factors may play a role in the ability to cope with stress. In children, relatively little research has been conducted to determine the impact of genetic factors on the variability in HPA axis functioning. In the present exploratory investigation, 106 prepubertal children were studied to estimate the impact of four glucocorticoid receptor gene (NR3C1) polymorphisms (NR3C1-1 [rs10482605], ER22/23EK [rs6190], N363S [rs6195], N766N [rs6196]) and five arginine vasopressin (AVP) receptor 1b gene (AVPR1b) polymorphisms (AVPR1b_s1 [rs28536160], AVPR1b_s2 [rs28373064], AVPR1b_s3 [rs33976516], AVPR1b_s4 [rs33985287], AVPR1b_s5 [rs33933482]) on cortisol responses after a psychosocial stress test (public speaking task). ER22/23EK carriers had significantly lower cortisol responses to psychosocial stress compared with noncarriers. These findings provide evidence for the relevance of the ER22/23EK polymorphism in childhood HPA axis regulation. However, the small number of ER22/23EK subjects does not allow us to draw definitive conclusions about the genotypic effect.

Serum testosterone concentration in male autistic youngsters.

OBJECTIVE: Research on the biological pathophysiology of autism has found some evidence that alterations in androgenic hormones may play a role in the pathophysiology of that disorder. We studied morning concentrations of serum testosterone in a very homogenic group of postpubertal youngsters with autism and a group of normal controls. METHODS: This study examines the serum testosterone concentration on 9 consecutive time points between 08.00 AM and 12.00 AM in 18 high- functioning male youngsters with autism (age 12-18) and 22 healthy volunteers participated in this study. All subjects passed the onset of puberty (Tanner-stage III-IV) and were of the Caucasian race. RESULTS: Repeated measures ANOVA revealed a significant time effect, with a decline in the testosterone concentration during the test and time X diagnosis interaction.The total testosterone concentration was significantly lower in the autism group compared to the group of normal controls. CONCLUSIONS: The significant decrease in serum testosterone concentration in male youngsters with autism suggest that the turnover of testosterone may take part in the pathophysiology of autism. Suggestions for further research are discussed.

Research projects in the collaborative antwerp psychiatric research institute.

INTRODUCTION: In the following article CAPRI presents its current research projects. SUBJECTS AND METHOD: The team leaders were asked to present and summarize the project they had been working on. The fields in which research was conducted are: Child and Adolescent Psychiatry, Cognitive and Psychomotor Dysfunctions in Schizophrenia, fMRI in Schizophrenia, Cognitive and Psychomotor Dysfunctions in Major Depressive Disorder, Chronic Fatigue Syndrome, Addiction Medicine and Forensic Psychiatry. RESULTS: An overview of recent and ongoing research projects is provided and the main results are summarized.

Screening for psychopathology in child welfare: the Strengths and Difficulties Questionnaire (SDQ) compared with the Achenbach System of Empirically Based Assessment (ASEBA).

Whilst children in child welfare suffer more psychopathology than their community peers, only a small percentage of them actually receive mental health care. Previous literature suggested that all children entering child welfare should be screened. This study evaluated whether the Strengths and Difficulties Questionnaire (SDQ) could be used for this purpose. The extended version of the SDQ and the Achenbach System of Empirically Based Assessment (ASEBA) questionnaire were administered to parents and caregivers of 292 children in child welfare. Children older than 11 years also completed the SDQ self-report and the Youth Self Report (YSR). Furthermore, the child's history of service use was recorded and informants were asked if the actual care was sufficient. Inter-informant correlations for the scores from the SDQ and ASEBA were high and comparable or favoured the use of the SDQ (for parents and caregivers). Internal consistency was satisfactory to good. For all informants, high correlations were found between SDQ and ASEBA. Despite high scores on the SDQ, only 29% of the children had received mental health care. Service use was only correlated with the parent SDQ and the CBCL and TRF. Additional help, as requested by 21% of the parents and 37% of the caregivers, correlated moderately with the SDQ and ASEBA scores. Compared to the total difficulties score, the impact supplement is a better predictor of service use and the informant's request for additional help. This study illustrates that the Dutch version of the SDQ, similar to the English and German versions, has equal validity as the Dutch ASEBA for screening children. Caution is warranted when the SDQ is the only source of information for referrals to specialized care.

Differences in hypothalamic-pituitary-adrenal axis functioning among children with ADHD predominantly inattentive and combined types.

Some evidence suggests that the HPA axis may be dysfunctional in children with attention-deficit/hyperactivity disorder (ADHD). The aim of this study was to investigate whether a different pattern of HPA axis activity is found between the inattentive (I) and combined (C) subtypes of ADHD, in comparison with healthy control children. A total of 100 prepubertal subjects [52 children with ADHD combined type (ADHD-C), 23 children with ADHD predominantly inattentive type (ADHD-I), and 25 healthy control subjects] were studied. The effects of stress were studied by comparing cortisol responses to a psychosocial stressor, consisting of a public speaking task. Children with ADHD-I showed an elevated cortisol response to the psychosocial stressor, in contrast to children with ADHD-C who showed a blunted cortisol response to the psychosocial stressor. When a distinction was made between responders and non-responders (a subject was classified as a responder when there was an increase in cortisol reactivity), hyperactivity symptoms were clearly related to a lower cortisol reactivity to stress. The results indicate that a low-cortisol responsivity to stress may be a neurobiological marker for children with ADHD-C, but not for those with ADHD-I. Directions for future research and clinical implications are discussed.

Adolescent suicidal ideation: a comparison of incarcerated and school-based samples.

BACKGROUND: The aim of this study was to investigate suicidal ideations and associated psychopathology in two groups of adolescents, a sample of detained youth and a general population sample. In both groups the comparisons of mental health characteristics between suicidal ideators and non-suicidal youth were conducted separately for girls and boys. METHODS: The study sample consisted of 290 delinquent adolescents [228 boys and 62 girls] from three Flemish juvenile detention centers and 1,548 adolescents [811 boys and 737 girls] from an age-matched school-based sample. Both groups were administered the Social and Health Assessment [SAHA], a self-report survey investigating levels of psychopathology [internalizing and externalizing] and risk-taking behavior. RESULTS: Suicidal ideations during the past year were reported by 21.5% of detained males, compared to 6.7% in the general population. In females, 58.1% of detained individuals reported suicidal thoughts during the past year, compared to 14.4% of the general population. In girls and boys from the general population, both internalizing and externalizing problems were higher in suicidal ideators than in non-suicidal youth, while in the detention group mainly internalizing problems were higher in suicidal ideators. When comparing detention suicidal ideators with those from the general population, male suicidal ideators scored higher on delinquency, while detained female suicidal ideators also scored higher on posttraumatic stress, but lower on prosocial beliefs. LIMITATIONS: Information used in this study was solely based on self-report measures only and limited to Flemish adolescents. CONCLUSION: Since suicidal ideation is a frequent problem in detained youth, adequate recognition and treatment seems clinically relevant. While both internalizing and externalizing psychopathology may be an indicator of suicidal ideation in the general population, internalizing problems may be the main clinical predictor in detained youth.

Personality symptoms and self-esteem as correlates of psychopathology in child psychiatric patients: evaluating multiple informant data.

Research on adulthood posits personality and self-esteem as important predictors of psychopathology. In childhood, however, the study of these relationships is complicated by the lack of consensus on how to combine data from multiple informants of child behavior. This study evaluates the relationships among personality symptoms, self-esteem and psychopathology in 60 child psychiatric patients (M (age) = 10.6) using principal component analysis (PCA) to aggregate data from multiple informants and compares this strategy with a single informant approach. When predictor and criterion measures were rated by a single informant, strong and differential relationships between personality symptoms, self-esteem and psychopathology are found. When multiple informant data were combined into composite scores by PCA, correlations decreased but remained significant. Hierarchical regression analyses affirm the robustness of the following pattern: Emotional Instability, Introversion and Global Self-Esteem are associated with internalizing whereas Disagreeableness and Behavioral Conduct primarily relate to externalizing problems.

Hypothalamic-pituitary-adrenal reactivity in prepubertal children with social phobia.

BACKGROUND: The aim of this study was to investigate whether a different pattern of HPA axis activity is found between children with social phobia (SP) and healthy control children. METHODS: A total of 50 prepubertal subjects (25 children with SP and 25 healthy control subjects) were studied. The effects of stress were studied by comparing cortisol responses to a psychosocial stressor, consisting of a public speaking task. RESULTS: Children with SP showed an elevated cortisol response to the psychosocial stressor as compared with healthy controls. Trait but not state anxiety levels are associated with higher HPA axis activity. LIMITATIONS: Limited sample size. CONCLUSIONS: The results indicate that a higher cortisol responsivity to stress may be a neurobiological marker for prepubertal children with SP. Directions for future research and clinical implications are discussed.

Faulty serotonin--DHEA interactions in autism: results of the 5-hydroxytryptophan challenge test.

BACKGROUND: Autism is accompanied by peripheral and central disorders in the metabolism of serotonin (5-HT). The present study examines plasma dehydroepiandrosterone-sulphate (DHEA-S) and the cortisol/DHEA-S ratio following administration of L-5-hydroxytryptophan (5-HTP), the direct precursor of 5-HT, to autistic patients. METHODS: Plasma DHEA-S levels were determined both before and after administration of 5-HTP or placebo, on two consecutive days in a single blind order in 18 male autistic patients and 22 matched healthy controls. RESULTS: The 5-HTP-induced DHEA-S responses were significantly higher in autistic patients than in controls. In baseline conditions, the cortisol/DHEA-S ratio was significantly higher in autistic patients than in controls. DISCUSSION: The results suggest that autism is accompanied by a major disequilibrium in the serotonergic system. The increased Cortisol (neurotoxic) versus DHEA-S (neuroprotective) ratio suggests that an increased neurotoxic potential occurs in autism. CONCLUSIONS: It is concluded that a disequilibrium in the peripheral and central turnover of serotonin and an increased neurotoxic capacity by glucocorticoids are important pathways in autism.

Sexual behavior in high-functioning male adolescents and young adults with autism spectrum disorder.

Group home caregivers of 24 institutionalized, male, high-functioning adolescents and young adults with Autism Spectrum Disorder, were interviewed with the Interview Sexuality Autism. Most subjects were reported to express sexual interest and to display some kind of sexual behavior. Knowledge of socio-sexual skills existed, but practical use was moderate. Masturbation was common. Many subjects were seeking physical contact with others. Half of the sample had experienced a relationship, while three were reported to have had sexual intercourse. The number of bisexual orientations appeared high. Ritual-sexual use of objects and sensory fascination with a sexual connotation were sometimes present. A paraphilia was present in two subjects. About one third of the group needed intervention regarding sexual development or behavior.

Central serotonergic hypofunction in autism: results of the 5-hydroxy-tryptophan challenge test.

Some studies have suggested that disorders in the central serotonergic function may play a role in the pathophysiology of autistic disorder. In order to assess the central serotonergic turnover in autism, this study examines the cortisol and prolactin responses to administration of L-5-hydroxy-tryptophan (5-HTP), the direct precursor of 5-HT in 18 male, post-pubertal, Caucasian autistic patients (age 13-19 y.; I.Q.>55) and 22 matched healthy volunteers. Serum cortisol and prolactin were determined 45 and 30 minutes before administration of 5-HTP (4 mg/kg in non enteric-coated tablets) or an identical placebo in a single blind order and, thereafter, every 30 minutes over a 3-hour period. The 5-HTP-induced increases in serum cortisol were significantly lower in autistic patients than in controls, whereas there were no significant differences in 5-HTP-induced prolactin responses between both study groups. In baseline conditions, no significant differences were found in serum cortisol and prolactin between autistic and normal children. The results suggest that autism is accompanied by a central serotonergic hypoactivity and that the latter could play a role in the pathophysiology of autism.

Glucocorticoid receptor gene-based SNP analysis in patients with recurrent major depression.

Dysregulation of the hypothalamic-pituitary-adrenal axis, one of the stress-response systems, is one of the key neurobiological features of major depression (MDD). Data supporting the notion that glucocorticoid-mediated feedback inhibition is impaired in MDD come from a multitude of studies demonstrating nonsuppression of cortisol secretion following administration of the synthetic glucocorticoid dexamethasone. We examined whether genetic variations in the glucocorticoid receptor gene (Nuclear Receptor Subfamily 3, Group C, Member 1; NR3C1) could be associated with increased susceptibility for MDD using a whole gene-based association analysis of single nucleotide polymorphisms (SNPs). Four SNPs were identified in NR3C1 and genotyped in two well-diagnosed samples of patients with MDD ascertained in Belgium and northern Sweden, and matched control samples. In total, 314 MDD patients and 354 control individuals were included in the study. In the Belgian sample, we observed significant allele (p=0.02) and genotype (p=0.02) association with an SNP in the promoter region (NR3C1-1); in the Swedish sample, we observed significant allele (p=0.02) and genotype (p=0.02) association with the R23K SNP. The haplotype association studies showed modest evidence for an involvement of the 5' region of the NR3C1 gene in the genetic vulnerability for MDD. This study suggests that polymorphisms in the 5' region of the NR3C1 gene may play a role in the genetic vulnerability for MDD.

Polyunsaturated fatty acids: do they have a role in the pathophysiology of autism?

OBJECTIVES: There is now some evidence that alterations in fatty acids may play a role in the pathophysiology of autism. The aim of the present study was to examine whether autism is accompanied by abnormalities in the composition of the polyunsaturated fatty acids (PUFAs) in plasma phospholipids. METHODS: The plasma phospholipid omega-3 (3) and omega-6 (6) PUFA fractions and the 3/6 ratio were measured in 16 high-functioning male youngsters with autism (age 12-18) and 22 healthy volunteers. Group mean differences were assessed by means of analysis of variance (ANOVA). RESULTS: In autism there was a significant increase in the fraction of C22:6-3 (docosahexaenoic acid, DHA) and an increase in the total 3/6 ratio. DISCUSSION: The results of this study suggest that an increase of the plasma phospholipid 3 PUFAs, in particular DHA, and of the total 3/6 ratio may take part in the pathophysiology of autism. One hypothesis is that an increase of 3 PUFAs may cause alterations in the serotonergic turnover and the immune response system, both known to be associated with autism. Caution must be exercised against highly concentrated 3 PUFAs supplementation.

The Impact of Idle Time in the Classroom: Differential Effects on Children With ADHD.

OBJECTIVE: Studies have identified an exacerbation of ADHD deficits under specific laboratory conditions. Less is known about the significance of such contextual factors in relation to everyday functioning in naturalistic settings. METHOD: This study investigated the differential impact of classroom "idle time"--periods when students are not actively engaged or waiting for a task--on the behavior of 31 children with ADHD (25 boys and 6 girls; aged 6-12 years) and 31 sex- and age-matched typically developing classmates, who were simultaneously observed in their normal classroom during two school days. RESULTS: Both groups experienced the same amount of idle time (12% of the time). During idle time, however, levels of hyperactivity and noisiness increased significantly more in children with ADHD than in their classmates (p < .05). CONCLUSION: Findings highlight the differential susceptibility of ADHD children to classroom idle time. Classroom interventions might consider targeting specifically these periods to reduce disruptive behavior in these children.

Suicidal behaviour in adolescents: associations with parental marital status and perceived parent-adolescent relationship.

BACKGROUND: Because equivocal findings exist with regard to the relationship between adolescents' suicidal behaviour and parental marital status, the aim of this study was to investigate this relationship and in particular the effect of the perceived parent-adolescent relationship on this association, taking into account the role of gender. METHOD: For this purpose, self-report surveys were administered to a representative school-based sample of 2707 adolescents in Antwerp (Belgium). RESULTS: 1) Boys living in a single parent family reported more suicidal ideations and self-harming behaviour than boys living in an intact family or in a remarried family; 2) Girls living in a remarried family reported more suicidal ideations and self-harming behaviour than girls living in an intact or in a single parent family; 3) Even after controlling for the levels of perceived parent-adolescent relationship, these associations remained significant. LIMITATIONS: The cross-sectional design, the retrospective assessment of suicidality and changes in family structure, the lack of external information and the assessment of the parent-adolescent relationship for both parents together, may have influenced the findings. CONCLUSIONS: When assessing risk factors for adolescent suicidality, marital status of the parents may bear clinical importance. In contrast to other studies, the perceived parent-adolescent relationship did not alter this association, a finding that needs further study.