Child and adolescent mental health multiaxial classification: A useful biopsychosocial framework for paediatrics?

In child and adolescent psychiatry, the multiaxial classification approach has been developed over some decades and remains very relevant as it encapsulates the biopsychosocial approach, an approach which is also central to paediatric practice. There is considerable overlap between developmental-behavioural paediatrics and child and adolescent mental health, including presenting clinical problems, diagnoses, multidisciplinary and holistic approach to assessment and management, and similar use of pharmacological agents and psychosocial interventions. Multiaxial classification can be of use to paediatricians in a variety of ways, both in clinical practice and for teaching purposes. It can improve communication between the two disciplines and promotes a more holistic diagnostic representation in a structured and consistent format. Presented here are a number of practical ways in which the multiaxial biopsychosocial framework can be used, including case description, formulation, timeline and interventions, training and teaching.

Pseudo-seizure, an Atypical Presentation of Attention-Deficit Hyperactivity Disorder in a Female: A Case Report.

BACKGROUND: This paper describes pseudo-seizure as an atypical presentation of attention-deficit hyperactivity disorder (ADHD) in an adolescent female in the context of psychosocial difficulties. We present the case, which explains the clinical dilemma in such situations, along with selective literature review. CASE PRESENTATION: An adolescent female, who is an academic high achiever, living with parents, presented with unresponsive spells which were initially treated with antiepileptics by the paediatrician without any significant improvement. Later, after further assessments and revision of her diagnosis to conversion disorder, she was referred to the child and youth mental health service team. Further evaluation revealed her symptoms to be a result of multiple psychosocial stressors in the context of her having undiagnosed ADHD. Individual therapy, treatment with stimulant, resulted in significant improvement in her school and home adjustments. CONCLUSIONS: This case demonstrates the diagnostic challenges that high-functioning girls with ADHD coloured by psychosocial stressors can pose and raises the need for reviewing our diagnostic approaches in these situations.

Multiaxial classification in child and adolescent mental health - a reaffirmation of benefit and practical applications.

OBJECTIVE: Classification systems and their practical implications have become increasingly important in child and adolescent psychiatry. This paper presents the evolution and practical applications of a multiaxial classification system for children and adolescents presenting to mental health services. Included are some worked examples demonstrating both the complexity of many presentations and how broadening the use of the multiaxial system can help in identifying appropriate interventions. CONCLUSIONS: Classification systems in child and adolescent psychiatry have largely remained uniaxial in nature. A multiaxial system encapsulates the broader biopsychosocial aspects of the presenting child or adolescent, and orders complex data in a concise manner. This approach can be used to concisely communicate with other treating clinicians, and assist with case reviews, formulation and teaching.

Absconding from Public Mental Health Inpatient Units - Who Does it, and why?

Patients who abscond from acute inpatient psychiatric wards put themselves and others at risks of variable nature and severity. There is a limited understanding of what motivates them to do so. The research in this area is limited and predominantly outdated. To better understand the characteristics, patterns and predictors of people who abscond from hospital, this study compared absconding and non-absconding patients in a tertiary public hospital. Demographic and clinical characteristics were audited for patients who absconded (n = 159) and who did not abscond (n = 100) throughout a 2-year period. Patients who absconded in the public settings were more likely to be male, have suffered from a psychotic illness, had an increased number of psychiatric comorbidities, had a history of aggression, and used greater numbers of substances. They also had experienced homelessness, were case managed, and were managed as involuntary patients. Predictors were similar, and included involuntary legal status, greater number of substances used, greater numbers of comorbid psychiatric illnesses, polysubstance use, an absence of self-harm history, shorter duration of admission and male sex. This study has implications for the identification of those who are at greater risk of absconding from an inpatient unit. Through enhanced understanding, greater measures can be taken to minimise absconding and its associated risks.

Profiling Absconders from Public and Private Inpatient Psychiatric Units: a Comparative Analysis.

Research related to absconding and its associated risks is limited in relation to inpatients from private psychiatric units. This study aimed to compare patients who abscond from public and private psychiatric inpatient settings. Demographic data was collated on the subjects (n = 214) who all had a history of absconding. Public absconders (n = 159) were more likely to have a psychotic illness, increased number of psychiatric diagnoses, history of aggression, substance use and homelessness, when compared to private absconders. Predictors identified for private absconders (n = 55) were female gender and fewer drugs used. This study has implications for the different profiles of absconders between the public and private settings.

Management of stuttering using cognitive behavior therapy and mindfulness meditation.

Stuttering is a speech fluency disorder with varied etiological explanations. It is important to identify symptoms early so that adequate and timely intervention can be delivered with focus on management and recovery. Stuttering, besides affecting speech fluency, might have a number of negative psychosocial consequences for the sufferer that may lead to immense anxiety, besides other symptoms. Therefore, it is thus imperative to include multiple dimensions in the holistic treatment of stuttering. Cognitive behavior therapy and mindfulness equip the client with the skills to manage the problems that occur as a result of stuttering. Since the rate of relapse in this condition is high, the chosen therapeutic paradigm must involve booster sessions over a long term. Periodic, detailed assessment would update the therapist about the barriers in treatment and would help in devising appropriate methods to get rid of these hindrances.

Psychosis in paratyphoid fever - a case report from Australia.

OBJECTIVE: Neuropsychiatric presentation in paratyphoid fever is not a well-known entity. In countries such as Australia, where the prevalence of enteric fever is one of the lowest, this presentation seems to be unlikely. METHOD: We present a case that demonstrates the importance of considering this possibility in Australian context in returned travellers. RESULTS: A young male, who recently returned to Australia from his home country in South East Asia, presented with abnormal behaviour in the context of febrile illness. His behaviour was characterised by grandiosity, aggression, hallucinatory behaviour and paranoia, along with disturbed biological functions. Detailed inpatient assessment revealed him to be suffering from Salmonella Paratyphi A infection and psychotic illness because of his general medical condition. Although his fever and inflammatory markers responded to antibiotics, antipsychotics were required for treatment of his mental health problems. CONCLUSION: This case demonstrates that paratyphoid fever, which is considered to be a less common variant of enteric fever, can present with neuropsychiatric manifestations.

Treatment for late-onset obsessive-compulsive disorder with parkinsonism.

Dysfunction of the basal ganglia and frontal subcortical structures occurs in both obsessive-compulsive disorder and parkinsonism. Treatment of obsessive-compulsive disorder with parkinsonism is a therapeutic challenge, especially in old age as selective serotonin reuptake inhibitors may aggravate motor symptoms and worsen clinical conditions. The authors present a series of patients with late onset obsessive-compulsive disorder demonstrating improvement in obsessive-compulsive disorder as well as parkinsonian signs.