Intoxicated persons showing challenging behavior demand complexity interventions: a pilot study at the interface of the ER and the complexity intervention unit.

Intoxicated persons showing challenging behavior (IPCBs) under influence of alcohol and/or drugs frequently have trouble finding appropriate acute care. Often IPCBs are stigmatized being unwilling or unable to accept help. Separated physical and mental healthcare systems hamper integrated acute care for IPCBs. This pilot aimed to substantiate the physical, psychiatric, and social health needs of IPCBs visiting the emergency room (ER) during a 3-month period. All ER visits were screened. After triage by the ER physician, indicated IPCBs were additionally assessed by the consultation-liaison-psychiatry physician. If needed, IPCBs were admitted to a complexity intervention unit for further examinations to provide integrated treatments and appropriate follow-up care. The INTERMED and Health of the Nation Outcome Scale (HoNOS) questionnaires were used to substantiate the complexity and needs. Field-relevant stakeholders were interviewed about this approach for acute integrated care. Alongside substance abuse, almost half of identified IPCBs suffered from comorbid psychiatric disturbances and one third showed substantial physical conditions requiring immediate medical intervention. Almost all IPCBs (96%) accepted the acute medical care voluntarily. IPCBs showed high mean initial scores of INTERMED (27.8 ± 10.0) and HoNOS (20.8 ± 6.9). At discharge from the complexity intervention unit, the mean HoNOS score decreased significantly (13.4 ± 8.6; P < 0.001). Field-relevant stakeholders strongly supported the interdisciplinary approach and ER-facility for IPCBs and acknowledged their unmet health needs. A biopsychosocial assessment at the ER, followed by a short admission if necessary, is effective in IPCBs. This approach helps to merge separated healthcare systems and may reduce stigmatization of IPCBs needing help.

Optimizing foster family placement for infants and toddlers: A randomized controlled trial on the effect of the foster family intervention.

The relationship between foster children and their foster carers comes with many risks and may be very stressful both for parents and children. We developed an intervention (foster family intervention [FFI]) to tackle these risks. The intervention focuses on foster children below the age of 5 years. The objective was to investigate the effects of FFI on the interactions between foster parents and foster children. A randomized control trial was carried out with a sample of 123 preschool aged children (mean age 18.8 months; 51% boys) and their foster carers. A pretest was carried out 6 to 8 weeks after placement and a posttest one half year later. Interactions were videotaped and coded using the Emotional Availability Scales (EAS). Foster carers were asked to fill in the Dutch version of the Parenting Stress Index. Morning and evening samples of children's salivary cortisol were taken. In the posttest, significantly positive effects were found on the following EAS subscales: Sensitivity, Structuring, Nonintrusiveness, and Responsiveness. We found no significant differences on stress levels of foster carers and children (Nijmeegse Ouderlijke Stress Index domains and salivary cortisol). This study shows that the FFI has a significant positive effect on parenting skills as measured with EAS and on Responsiveness of the foster child. Findings are discussed in terms of impact and significance relating to methodology and design of the study and to clinical relevance. (PsycINFO Database Record

Training in psychiatry throughout Europe.

Psychiatry is the largest medical specialty in Europe. Despite efforts to bring harmonisation, training in psychiatry in Europe continues to be very diverse. The Union Européenne des Médecins Spécialistes (UEMS) has issued as from 2000 a charter of requirements for the training in psychiatry with an additional European Framework for Competencies in Psychiatry in 2009. Yet these have not been implemented throughout Europe. In this paper, the diversity in training throughout Europe is approached from different angles: the cultural differences between countries with regards to how mental health care is considered and founded on, the cultural differences between people throughout Europe in all states. The position of psychotherapy is emphasised. What once was the cornerstone of psychiatry as medical specialty seems to have become a neglected area. Seeing the patient with mental health problems within his cultural context is important, but considering him within his family context. The purpose of any training is enabling the trainee to gain the knowledge and acquire the competencies necessary to become a well-equipped professional is the subject of the last paragraph in which trainees consider their position and early career psychiatrists look back to see whether what they were trained in matches with what they need in the working situation. Common standard for training and certification are a necessity within Europe, for the benefit of the profession of psychiatrist but also for patient safety. UEMS is advised to join forces with the Council of National Psychiatric Associations (NPAs) within the EPA and trainings and early career psychiatrist, to discuss with the users what standards should be implemented in all European countries and how a European board examination could ensure professional quality of psychiatrists throughout the continent.

[Intensive home treatment of adolescents in crisis: treat the parents along with 'psychiatric' adolescents]. / Intensieve thuisbehandeling van jongeren in crisis: behandel ouders mee bij 'psychiatrische' adolescenten.

OBJECTIVE: To investigate whether a new intensive home treatment (IHT) model for adolescents with psychiatric problems is more effective or more efficient than previous treatment methods involving long-term clinical admission. DESIGN: Descriptive, retrospective study. METHOD: The previous treatment model for adolescents in crisis consisted of clinical admission for 6 months or longer. To implement the new treatment model, 4 admission wards with 34 beds were converted to 1 'high & intensive care' (HIC) ward with 7 beds, in combination with IHT care for the family in the home environment. Admission to the HIC is short-term, and the parents are admitted along with their child. The new model was used from May 2013. The number of patients receiving care, the length of treatment, patient satisfaction, the number of beds and the costs were investigated and compared with data from the years 2011 and 2012. RESULTS: In comparison with the previous treatment model, this IHT treatment model revealed that more adolescents could be treated in the course of 1 year (125 compared with 70 per year) with a shorter duration of treatment (2 weeks clinical admission if required and 4 months ambulatory treatment, compared with 6 to 7 months clinical treatment) and with lower costs (€ 28,000 compared with € 55,000) with the same level of patient satisfaction. CONCLUSION: Although initial treatment results are positive, more extensive investigation is required into treatment effectiveness and cost efficiency of the IHT model for adolescents over a longer period of time.

Temperament and character as endophenotype in adults with autism spectrum disorders or attention deficit/hyperactivity disorder.

Autism spectrum disorder and attention deficit/hyperactivity disorder overlap in several ways, raising questions about the nature of this comorbidity. Rommelse et al. published an innovative review of candidate endophenotypes for autism spectrum disorder and attention deficit/hyperactivity disorder in cognitive and brain domains. They found that all the endophenotypic impairments that were reviewed in attention deficit/hyperactivity disorder were also present in autism spectrum disorder, suggesting a continuity model with attention deficit/hyperactivity disorder as "a light form of autism spectrum disorder." Using existing data, 75 adults with autism spectrum disorder and 53 with attention deficit/hyperactivity disorder were directly compared on autistic symptoms with the autism spectrum quotient, and on the endophenotypic measure of temperament and character, using the Abbreviated (Dutch: Verkorte) Temperament and Character Inventory. Based on the hypothesis that attention deficit/hyperactivity disorder and autism spectrum disorder are disorders on a continuous spectrum, autism spectrum quotient scores and abbreviated Temperament and Character Inventory scores were expected to be different from normal controls in both disorders in a similar direction. In addition, the autism spectrum quotient and abbreviated Temperament and Character Inventory scores were expected to be closely correlated. These conditions applied to only two of the seven Abbreviated Temperament and Character Inventory scales (harm avoidance and self-directedness), suggesting that temperament and character as an endophenotype of autism spectrum disorder and attention deficit/hyperactivity disorder provides only partial support for the continuity hypothesis of autism spectrum disorder and attention deficit/hyperactivity disorder.

Raising a child with an Autism Spectrum Disorder: 'If this were a partner relationship, I would have quit ages ago'.

BACKGROUND: The aim of the study was to determine the experiences of parents having a child with Autism Spectrum Disorder (ASD) and what kind of support parents would like to receive in primary care. METHODS: Interviews were held with 29 main caregivers, in combination with a standardized questionnaire on quality of life. RESULTS: Virtually all parents experienced tremendous shortcomings as a caregiver of their affected child and therefore felt guilty both towards their child with ASD and towards their other children. Most parents felt the burden was beyond their possibilities. The perceived physical and mental health was rather fair. They also wished that healthcare professionals should properly listen to them and must share their decisions instead of making decisions without them having a say. They mostly appreciated practical tips for every day handling the child. CONCLUSIONS: The burden on parents of raising a child with ASD is too high. Parents like caregivers to listen carefully to their experiences and to facilitate shared decision-making. Outreaching professionals who provide practical assistance are most highly valued.

Atomoxetine in autism spectrum disorder: no effects on social functioning; some beneficial effects on stereotyped behaviors, inappropriate speech, and fear of change.

UNLABELLED: Abstract Objective: The objective of this study was to investigate the short-term treatment effects of atomoxetine on autism spectrum disorder (ASD) symptoms in children and adolescents with both ASD and attention-deficit/hyperactivity disorder (ADHD). METHODS: A total of 97 patients 6-17 years of age, with ASD and ADHD, were treated with 1.2 mg/kg/day of atomoxetine during an 8 week double-blind placebo-controlled period. Here, we investigated effects on two parent-based secondary outcome measures, the Aberrant Behavior Checklist (ABC) and the Children's Social Behavior Questionnaire (CSBQ). RESULTS: After 8 weeks of double-blind treatment, atomoxetine administration was associated with significant treatment effects on the ABC subscales Hyperactivity, Inappropriate Speech, and Stereotypic Behavior, and on the CSBQ subscale Fear for Changes. CONCLUSIONS: Our study results indicate no beneficial effects of atomoxetine on social functioning. However, atomoxetine may ameliorate restricted and stereotyped behaviors and communication. This study has been registered in ClinicalTrials.gov ( www.clinicaltrials.gov ) under registration number NCT00380692.

Improving patient care for attention deficit hyperactivity disorder in children by organizational redesign (Tornado program) and enhanced collaboration between psychiatry and general practice: a controlled before and after study.

BACKGROUND: Implementation of clinical guidelines for diagnosis and treatment of attention deficit hyperactivity disorder (ADHD) in children and adolescents is a challenge in practice due to insufficient availability of mental health specialists and lack of effective cooperation with primary care physicians. The Tornado program aims to reduce time between referral and start of treatment in eligible patients. This study aims to assess the effectiveness and efficiency of this program. METHODS/DESIGN: This is a non-randomized controlled before-after study involving 90 outpatients (6-18 years old) suspected of uncomplicated ADHD, which were recruited by ten mental health teams. The Tornado program, provided by three teams, combines accelerated-track diagnosis and treatment planning. This is followed by psychoeducation at a mental health center and pharmacological treatment by primary care physicians, who received an online e-learning module for this purpose. The control group consists of patients of seven other teams, who receive care as usual. Primary outcome is the patients' time between referral to the mental health or pediatric center and start of treatment. Secondary outcomes include severity of ADHD symptoms; functional status; health-related quality of life; treatment adherence; indicators of diagnostic procedures and treatments; patient, parent, and professional experiences and satisfaction with care; and an economic evaluation. The study is powered to detect a difference of 36 days. DISCUSSION: This study will provide insight into the effectiveness and efficiency of the Tornado program, an accelerated-track program in mental healthcare. TRIAL REGISTRATION: Netherlands Trial Register NTR2505. TRIAL STATUS: Active data collection.

Gender and age differences in the core triad of impairments in autism spectrum disorders: a systematic review and meta-analysis.

Autism is an extensively studied disorder in which the gender disparity in prevalence has received much attention. In contrast, only a few studies examine gender differences in symptomatology. This systematic review and meta-analysis of 22 peer reviewed original publications examines gender differences in the core triad of impairments in autism. Gender differences were transformed and concatenated using standardized mean differences, and analyses were stratified in five age categories (toddlerhood, preschool children, childhood, adolescence, young adulthood). Boys showed more repetitive and stereotyped behavior as from the age of six, but not below the age of six. Males and females did not differ in the domain of social behavior and communication. There is an underrepresentation of females with ASD an average to high intelligence. Females could present another autistic phenotype than males. As ASD is now defined according to the male phenotype this could imply that there is an ascertainment bias. More research is needed into the female phenotype of ASD with development of appropriate instruments to detect and ascertain them.

Salivary cortisol: a possible biomarker in evaluating stress and effects of interventions in young foster children?

Young foster children undergo an early separation from their caregiver(s) and often experience severe stress before placement. However, a considerable part of the children do not show apparent signs of distress, making it difficult for the foster carer to be aware of the amount of stress in their foster child. Potential evidence for using salivary cortisol levels as a dimension to evaluate the amount of stress in young foster children is reviewed. Moreover, the applicability of salivary cortisol in the evaluation of stress-reducing interventions for young foster children is discussed. A systematic review was performed using the databases Medline, Psychinfo, Embase, Ebscohost, and Academic Search Premier. Nine studies were traced in which salivary cortisol was used to measure stress in children placed in family foster care or in adoptive families. Stress in general but also neglect, early loss of a caregiver, a younger age at first placement, and a higher number of placements were associated with an altered hypothalamic-pituitary-adrenal (HPA) axis function in foster children. Moreover, four studies on the effect of stress-reducing interventions on HPA-axis functioning of young foster children were found. These studies suggest that caregiver-based interventions can actually help to normalize the HPA-axis function in foster children, and that such changes co-occur with improved behavioral functioning. Although the results from the papers discussed in this review suggest that diurnal cortisol with a wake up and a bedtime measurement may be a relevant tool to evaluate stress in young foster children, this cannot yet be concluded from the present studies, because statistical data from the studies on foster care and adoption in this review were not robust and researchers used different methods to collect the salivary cortisol. Still, it is noteworthy that all studies did find the same pattern of reduced levels in relation to chronic stress (caused by maltreatment and neglect of the child).

Long-term treatment with atomoxetine for attention-deficit/hyperactivity disorder symptoms in children and adolescents with autism spectrum disorder: an open-label extension study.

OBJECTIVE: The efficacy and tolerability of long-term treatment with atomoxetine for symptoms of attention-deficit/hyperactivity disorder (ADHD) in children with autism spectrum disorder (ASD) has not been established. METHODS: In this study, 88 patients 6-17 years of age, with ADHD and ASD, were treated with 1.2 mg/kg/day atomoxetine for 20 weeks as follow-up of an 8 week double-blind placebo-controlled period. Primary endpoint was the ADHD Rating Scale (ADHD-RS). RESULTS: After 8 weeks of initial treatment, the mean total, inattention, and hyperactivity-impulsivity ADHD-RS further decreased significantly from 34.9 to 27.0 for the total ADHD-RS, from 18.3 to 14.5 for the ADHD-RS inattention subscale, and from 16.5 to 12.6 for the hyperactivity-impulsivity subscale. Adverse events were mild and tended to diminish over time during continued treatment, especially regarding nausea and fatigue. There were no serious adverse events. CONCLUSIONS: The results of the present analysis suggest that continued treatment with atomoxetine up to 28 weeks further improve ADHD symptoms in children and adolescents with ASD, while adverse events tend to subside. Future studies investigating the long-term efficacy of atomoxetine in children and adolescents with ASD should be randomized and placebo controlled. This study has been registered in ClinicalTrials.gov ( www.clinicaltrials.gov ) under registration number NCT00380692.

How to use the ADI-R for classifying autism spectrum disorders? Psychometric properties of criteria from the literature in 1,204 Dutch children.

The algorithm of the Autism Diagnostic Interview-Revised provides criteria for autism versus non-autism according to DSM-IV. Criteria for the broader autism spectrum disorders are needed. This study investigated the validity of seven sets of criteria from the literature, in 1,204 Dutch children (aged 3-18 years) with and without mental retardation. The original criteria (Rutter et al. in ADI-R Autism Diagnostic Interview Revised. Manual. Western Psychological Services, Los Angeles, 2003) well discriminated ASD from non-ASD in MR. All other criteria (IMGSAC in Am Soc Hum Genet 69:570-581 2001; Sung et al. in Am J Hum Genet 76: 68-81, 2005; Risi et al. in J Am Acad Child Adolesc Psychiatry 45: 1094-1103, 2006) were sensitive at the cost of specificity, bearing the risk of overinclusiveness. In the group without MR, clinicians should decide whether sensitivity or specificity is aimed for, to choose the appropriate criteria. Including the Autism Diagnostic Observation Schedule revised algorithms in the classification, the specificity increases, at the cost of sensitivity. This study adds to a more valid judgment on which criteria to use for specific objectives.

Head circumference and height abnormalities in autism revisited: the role of pre- and perinatal risk factors.

Pre/perinatal risk factors and body growth abnormalities have been studied frequently as early risk markers in autism spectrum disorder (ASD), yet their interrelatedness in ASD has received very little research attention. This is surprising, given that pre/perinatal risk factors can have a substantial impact on growth trajectories in the first years of life. We aimed to determine which pre/perinatal factors were more prevalent in ASD children and if these factors differentially influenced body growth in ASD and control children. A total of 96 ASD and 163 control children matched for gender participated. Data of growth of head size and body length during the first 13 months of life were collected. Data on pre/perinatal risk factors were retrospectively collected through standardized questionnaires. Results indicated that after matching for SES, prematurity/low birth weight and being first born were more prevalent in the ASD versus the control group. In addition, with increasing age children with ASD tended to have a proportionally smaller head circumference compared to their height. However, the effect of prematurity/low birth weight on head growth corrected for height was significantly different in ASD and control children: premature/low birth weight control children showed a disproportionate larger head circumference in relation to height during their first year of life, whereas this effect was absent in premature/low birth weight ASD children. This may suggest that the etiology of abnormal growth is potentially different in ASD and control children: where abnormal growth in control children is related to suboptimal conditions in the uterus, abnormal growth in ASD may be more strongly related to the causal factors that also increase the risk for ASD. However, prospective studies measuring growth and ASD characteristics in both premature/low birth weight and a terme children are necessary to support this conclusion.

The state of psychiatry in the Netherlands: strength by quality, influence by capabilities.

Psychiatry and mental healthcare in the Netherlands has a long history of institutional care, slowly more adapted to the community, but differentiated from mainstream healthcare in terms of organization and remuneration. It is in a crucial phase of reconsideration. Along with harsh cuts on the budgets in healthcare, the field is in transition where training is concerned. The good news is that in fruitful cooperation the government and all spcialist parties involved in mental healthcare are on the verge of reaching an important agreement that should make mental healthcare more patient centred, affordable and accessible for those who need it. The bad news that needs serious consideration and ongoing action is that mental health problems are still highly stigmatized and that as a result the government could impose an unjust and unfair own financial contribution for users in mental care as a means of lowering the costs in the field.

Visual scanning in very young children with autism and their unaffected parents.

This study of gaze patterns in very young children with autism and their parents included 23 cases (with 16 fathers and 19 mothers) and 46 controls (with 14 fathers and 28 mothers). Children (mean age 3.3 ± 1.5 years) with autism met DSM-IV and ADOS-G diagnostic criteria. The participants' gaze patterns were recorded while they viewed four simple movies that did not feature people. In children, severity of autism is related to spending more time watching irrelevant regions in one of the four movies. The mothers of children with autism showed an atypical pattern for three movies, whereas the fathers of children with autism did not show an atypical gaze pattern. The gaze pattern of the mothers was positively correlated with that of their children. The atypical viewing pattern of autistic individuals appears not to be restricted to people and social situations but is also seen in other situations, suggesting that there is a perceptual broad autism phenotype.

A randomized double-blind study of atomoxetine versus placebo for attention-deficit/hyperactivity disorder symptoms in children with autism spectrum disorder.

OBJECTIVE: The efficacy of atomoxetine as treatment of symptoms of attention-deficit/hyperactivity disorder (ADHD) in patients with autism spectrum disorder (ASD) has not been established. METHOD: In this study, 97 patients aged 6 to 17 years with ADHD and ASD were randomly assigned to double-blind treatment with 1.2 mg/kg/day atomoxetine or placebo for 8 weeks. The primary endpoint was the ADHD Rating Scale (ADHD-RS) score; secondary endpoints were the Clinical Global Impression of ADHD-Improvement (CGI-I) and the Conners Teacher Rating Scale-Revised: Short Form (CTRS-R:S) score. RESULTS: Baseline mean ADHD-RS scores for atomoxetine versus placebo were 40.7 and 38.6; after 8 weeks, mixed-effect model repeated-measure means were 31.6 (95% confidence interval 29.2-33.9) and 38.3 (36.0-40.6), respectively, with a difference in least square means of -6.7 (-10.0 to -3.4; p < .001). The CTRS-R:S Hyperactivity subscore also improved significantly for atomoxetine compared with placebo, but not the other CTRS-R:S subscores. However, there were not significantly more patients on atomoxetine (20.9%) who improved much, or very much according to the CGI-I, than on placebo (8.7%; p = 0.14). Adverse events (mostly nausea, decrease in appetite, fatigue, and early morning awakening) were reported in 81.3% of atomoxetine patients and 65.3% of placebo patients (p > .1). There were no serious adverse events. CONCLUSIONS: Atomoxetine moderately improved ADHD symptoms in patients with ASD and was generally well tolerated. Adverse events in this study were similar to those in other studies with ADHD patients without ASD. Clinical trial registration information-A Randomized Double-Blind Study of Atomoxetine Versus Placebo for ADHD Symptoms in Children with ASD; www.clinicaltrials.gov; NCT00380692.

Effects of attentional/ hyperactive and oppositional/ aggressive problem behaviour at 14 months and 21 months on parenting stress.

BACKGROUND: To evaluate effects of attentional/ hyperactive (Att/Hi) and oppositional/ aggressive (Opp/Agg) behaviours of children at 14 and 21 months of age on parenting stress at 21 months. METHOD: 107 children from the general population with low, intermediate, and high levels of disruptive behaviours at 14 months, as evaluated by parents on a 55-item checklist, participated. Parents completed the Child Behaviour Checklist 1.5-5 and the Dutch version of Parenting Stress Index (NOSI) at 21 months. Effects of problem behaviours were examined in a 2 (Att/Hi and Opp/Agg) by 2 (not high versus high) by 2 (14 and 21 months) multivariate design with parental stress as dependent variable. RESULTS: Oppositional/ aggressive behaviour at 14 months had a strong main effect on parenting stress, but not at 21 months. There was a significant interaction between parenting stress and Att/Hi behaviour at 14 and 21 months, indicating that increase in these behaviours over time was associated with parenting stress. Both Opp/Agg behaviour and an interaction between Att/Hi behaviour and parenting stress contributed to maternal role restriction and social isolation. Oppositional/ aggressive behaviour led to higher scores for parental competence and depression, whereas Att/Hi behaviour led to lower scores for attachment. CONCLUSIONS: Early Opp/Agg and Att/Hi behaviour had differential effects on parenting stress at 21 months. The increase in parenting stress associated with early Opp/Agg behaviour may be linked to overall feelings of parental competence, whereas the course of Att/Hi behaviour may be associated with increased demands on parent-child interactions and attachment. Our results have implications for development of early intervention programmes.

Mental health 'cure and care' in the Netherlands: risks and opportunities.

The practice of psychiatry and mental health services is influenced by social, economic and cultural factors. In this paper evidence from the Netherlands is presented. Like many other countries, shift from asylums to community care has meant a number of significant challenges. Changes in social and health policies and financial circumstances has led to changes in healthcare delivery. In addition these also impact upon training. Lessons from these changes are many and we need to learn from these so that patients can get the best treatments.

Neural correlates of language comprehension in autism spectrum disorders: when language conflicts with world knowledge.

In individuals with ASD, difficulties with language comprehension are most evident when higher-level semantic-pragmatic language processing is required, for instance when context has to be used to interpret the meaning of an utterance. Until now, it is unclear at what level of processing and for what type of context these difficulties in language comprehension occur. Therefore, in the current fMRI study, we investigated the neural correlates of the integration of contextual information during auditory language comprehension in 24 adults with ASD and 24 matched control participants. Different levels of context processing were manipulated by using spoken sentences that were correct or contained either a semantic or world knowledge anomaly. Our findings demonstrated significant differences between the groups in inferior frontal cortex that were only present for sentences with a world knowledge anomaly. Relative to the ASD group, the control group showed significantly increased activation in left inferior frontal gyrus (LIFG) for sentences with a world knowledge anomaly compared to correct sentences. This effect possibly indicates reduced integrative capacities of the ASD group. Furthermore, world knowledge anomalies elicited significantly stronger activation in right inferior frontal gyrus (RIFG) in the control group compared to the ASD group. This additional RIFG activation probably reflects revision of the situation model after new, conflicting information. The lack of recruitment of RIFG is possibly related to difficulties with exception handling in the ASD group.