Informative value of referral letters from general practice for child and adolescent mental healthcare.

Although referral letters (RLs) form a nodal point in a patient's care journey, little is known about their informative value in child and adolescent mental healthcare. To determine the informative value of RLs to child and adolescent psychiatry, we conducted a chart review in medical records of minors registered at specialized mental healthcare between January 2015 and December 2017 (The Netherlands). Symptoms indicated in RLs originating from general practice (N = 723) were coded and cross-tabulated with the best estimate clinical classifications made in psychiatry. Results revealed that over half of the minors in the sample were classified in concordance with at least one reason for referral. We found fair to excellent discriminative ability for indications made in RLs concerning the most common psychiatric classifications (95% CI AUC: 60.9-70.6 for anxiety disorders to 90.5-100.0 for eating disorders). Logistic regression analyses suggested no statistically significant effects of gender, age, severity or mental healthcare history, with the exception of age and attention deficit hyperactivity disorders (ADHD), as RLs better predicted ADHD with increasing age (OR = 1.14, 95% CI 1.03-1.27). Contextual problems, such as difficulties studying, problems with parents or being bullied were indicated frequently and associated with classifications in various disorder groups. To conclude, general practitioners' RLs showed informative value, contrary to common beliefs. Replication studies are needed to reliably incorporate RLs into the diagnostic work-up.

Sociodemographic and clinical characteristics in child and youth mental health; comparison of routine outcome measurements of an Australian and Dutch outpatient cohort.

AIMS: Although of great value to understand the treatment results for mental health problems obtained in clinical practice, studies using naturalistic data from children and adolescents seeking clinical care because of complex mental health problems are limited. Cross-national comparison of naturalistic outcomes in this population is seldomly done. Although careful consideration is needed, such comparisons are likely to contribute to an open dialogue about cross-national differences and may stimulate service improvement. The aim of this observational study is to investigate clinical characteristics and outcomes in naturalistic cohorts of specialized child and adolescent mental health outpatient care in two different countries. METHODS: Routinely collected data from 2013 to 2018 of 2715 outpatients in the Greater Area of Brisbane, Australia (CYMHS) and 1158 outpatients in Leiden, the Netherlands (LUMC-Curium) were analysed. Demographics, clinical characteristics and severity of problems at start and end of treatment were described, using Children's Global Assessment Scale (CGAS), Health of the Nation Outcome Scales for Children and Adolescents (HoNOSCA) and the parental Strength and Difficulties Questionnaire (SDQ-P). RESULTS: Routine outcome measures (CGAS, HoNOSCA, SDQ-P) showed moderate to severe mental health problems at start of treatment, which improved significantly over time in both cohorts. Effect sizes ranged between 0.73-0.90 (CYMHS) and 0.57-0.76 (LUMC-Curium). While internalizing problems (mood disorder, anxiety disorder and stress-related disorder) were more prevalent at CYMHS, externalizing developmental problems (ADHD, autism) prevailed at LUMC-Curium. Comorbidity (>1 diagnosis on ICD10/DSM-IV) was relatively similar: 45% at CYMHS and 39 % at LUMC-Curium. In both countries, improvement of functioning was lowest for conduct disorder and highest for somatoform/conversion disorders and obsessive-compulsive disorders (OCD). Overall, 20-40% showed clinically significant improvement (shift from clinical-range at start to a non-clinical-range at the end of treatment), but nearly half of patients still experienced significant symptoms at discharge. CONCLUSIONS: This large-scale outcome study showed both cohorts from Australia and the Netherlands improve during the course of treatment on clinician- and parent-reported measures. Although samples were situated within different contexts and differed in patient profiles, they showed similar trends in improvement per diagnostic group. While 20-40% showed clinically significant change, many patients experienced residual symptoms reflecting increased risk for negative outcome into adulthood. We emphasize cross-national comparison of naturalistic outcomes faces challenges, although it can similarly reveal trends in treatment outcome providing direction for future research: what factors determine discharge from specialized services; and how to improve current treatments in this severely affected population.

Separation anxiety and overanxious disorders: relations to age and level of psychosocial maturity.

OBJECTIVE: To study the developmental underpinnings of age trends in the prevalence of separation anxiety disorder (SAD) and overanxious disorder (OAD) in children and adolescents. METHOD: The sample consisted of 118 children and adolescents (aged 8-18 years) with SAD or OAD, who were referred to an outpatient psychiatric clinic. Anxiety disorders were assessed with Silverman and Nelles' Anxiety Disorders Interview Schedule for Children; level of psychosocial development was conceptualized and assessed by means of Jane Loevinger's model and measure of ego development. Logistic regression analyses were applied to study the extent to which age and level of ego development were related to the presence of SAD or OAD. RESULTS: Level of ego development was the strongest predictor of group membership (SAD versus OAD). Although age was a strong predictor as well, the age effect became insignificant after ego level had been entered into the regression equation. As predicted, SAD was related primarily to the Impulsive ego level, whereas OAD was related mostly to the Conformist ego level. The comorbid condition (SAD and OAD) fell squarely in between the 2 "pure" groups, both in terms of age and ego level. The results were controlled for possibly confounding variables, such as gender, IQ, and socioeconomic status. CONCLUSIONS: The presence of SAD and OAD appears to be related to specific levels of psychosocial maturity, irrespective of age.

Psychological effects of subclinical epileptiform EEG discharges in children. II. General intelligence tests.

Twenty-one children with suspected or proven epilepsy and subclinical epileptiform EEG discharges in the waking state were studied. The EEG was telemetered and behaviour recorded by closed-circuit television during performance of a general intelligence test (RAKIT, shortened version) which comprised 6 subtests. Mean total IQ was below that of control populations and the subtests profile was abnormal, due particularly to impaired performance on a subtest concerned with verbal short-term memory. This effect was accounted for by that subgroup of children who exhibited discharges during the test; those who did not show discharges at that time were unimpaired. Performance of 3 of the subtests was impaired when discharges occurred during presentation of the test item or between presentation and response. The findings suggest that cognitive impairment found in people with epilepsy may not only represent a more or less static disability, due to drugs, cerebral pathology, etc., but may in part be an intermittent process related to the occurrence of subclinical epileptiform discharges. These preliminary findings need to be amplified but have implications both for interpretation of neuropsychological studies in persons with epilepsy and also for the drug treatment of those who continue to exhibit subclinical EEG discharges when overt seizures have been controlled.

Handedness and progressive hydrocephalus in spina bifida patients.

Hand preference and functional hand-dominance of 45 spina bifida patients (aged 13 to 25 years) were assessed by means of self-reports on an ordinal scale and a tapping task. Non-right-handedness was more frequent among patients with accompanying progressive hydrocephalus. Left-hand preference was significantly more frequent in this group than in patients without shunts. Non-right-handedness in hydrocephalic patients correlated positively with the estimated degree of pre-operative progress of the hydrocephalus. The apparent failure to establish right-handedness in these patients seemed to reflect a developmental disorder of lateralization, related to a more advanced degree of progressive hydrocephalus at an early age. It is suggested that the disorder may be attributable to dysfunction of the corpus callosum, caused by delay in the development of callosal white matter when the hydrocephalus is in a progressive state.

Lateralized effects of subclinical epileptiform EEG discharges on scholastic performance in children.

The interaction between lateralization of subclinical epileptiform discharges and cognitive tasks was investigated in 21 children (12 girls and 9 boys, mean age 10.6 years). Seventeen had a diagnosis of epilepsy (partial or secondarily generalized). Testing was by reading, arithmetic, and intelligence subtests during continuous telemetric EEG and video monitoring. Children with left-sided discharges had significantly lower reading performance than children with right-sided discharges. During reading, epileptiform discharges occurred relatively less frequently and with a shorter total duration over the left hemisphere than the right. This supports the view that cognitive tasks suppress epileptiform discharges when they activate a region of the brain within the epileptogenic zone. Discharges from other epileptogenic zones not directly activated by the tasks are increased, however.