'They're not witches. ' Young children and their parents' perceptions and experiences of Child and Adolescent Mental Health Services.

BACKGROUND: Recent initiatives have emphasized the ongoing need to include children in healthcare research, which is relevant to the development of both paediatric and mental healthcare services. Our aim was to contribute children and their parents' perceptions and experiences of Child and Adolescent Mental Health Services (CAMHS), with the objective of providing guidance for those wishing to improve inclusivity and empowerment. METHOD: We performed a thematic analysis of interview data taken from 11 children (9 boys, 2 girls, aged 8-12) and their parents (12 mothers, 2 fathers), who had recently been referred to CAMHS for mental health and educational problems. RESULTS: Three core themes emerged from the data. Fear of the unknown refers to emotional apprehension due to uncertainty of what happens in CAMHS. However children also provided useful reassurances for future service users. Therapeutic engagement refers to the importance of being listened to and building up good relationships with professionals. Finally making services acceptable was discussed in terms of issues of accessibility, session tolerances and suggestions for the development of child-centred services. CONCLUSIONS: Children were able to provide potentially useful opinions of CAMHS. In a time of limited resources it is imperative that the voices of children and their parents are acknowledged in order to improve accessibility and experiences within CAMHS.

Mental health problems among labour children in the Gaza Strip.

BACKGROUND: There is increasing international concern over the rising number of children involved in labour, particularly in developing countries. Despite the multitude of related risk factors, and some evidence on their social needs, there has been limited research on these children's mental health. METHODS: The aim of this study was to establish the association between labour-related variables and mental health problems among 780 children in labour (aged 9-18 years, mean 15.8) in the Gaza Strip. Measures included a demographic checklist, the Strengths and Difficulties Questionnaire, the Spence Children's Anxiety Scale and the Depression Self-rating Scale for Children. RESULTS: Children came from large families (73.2% had eight or more siblings), mainly worked to increase family income, worked an average 6.8 h per day (range 1-16), and only 37.1% had regular rest. Ratings of mental health problems were predicted by different factors, i.e. total difficulties scores by poor friendship relationships and lack of health insurance; anxiety scores by selling in the streets, working to help family, low family income and lack of health insurance; and depression scores by parents' dissatisfaction with the job and longer working hours. CONCLUSIONS: Mental health problems of children in labour are likely to be associated with socio economic determinants, as well as factors related to their under age employment. Policy, legislation and preventive programmes from statutory and voluntary agencies should adopt an integrated approach in meeting their mental health needs, by enhancing protective factors such as return to school.

Attention deficit-hyperactivity symptoms among Palestinian children.

We aimed to establish the prevalence and distribution of attention deficit-hyperactivity disorder (ADHD) symptoms and other associated comorbid mental health problems in Palestinian schoolchildren. Thus 349 children aged 6-15 years were randomly selected from 23 schools in Gaza and the West Bank and were rated by their parents and teachers using both the ADHD DSM-IV Checklist and the Strengths and the Difficulties Questionnaire, which also measures conduct and emotional problems. There was a significant agreement between parents and teachers, with 4.3% of the children rated above the established cut-off scores on both the parent and teacher DSM-IV Checklist. Male gender, family size and living in an area of socioeconomic deprivation were independently associated with ADHD symptoms.

Children's specific fears.

BACKGROUND: Most children experience some degree of fear during their development. Specific fears are considered as an appropriate response provided that they are proportionate to the intensity of the perceived threat. Our aim is to present the prevalence of specific fears among children in the Great Britain, their socio-demographic correlates, in particular their association with ethnicity. METHODS: Data on the child's experience of specific fears were obtained from parents of a national representative sample of 5- to 16-year-olds using the Development and Well-Being Assessment. Biographic, socio-demographic and socioeconomic characteristics of the child and the family were included in the questionnaire. RESULTS: About one-third of children were assessed by their parents as having at least one of 12 specific fears. The most commonly reported fears were animals (11.6%), blood/injections (10.8%) and the dark (6.3%). Just less than 1% of all children were assessed according to International Classification of Diseases research diagnostic criteria as having a specific phobia. Biographic, socio-demographic and socioeconomic factors were independently associated with a greater likelihood of a child having particular fears. The most marked associations were fears of the dark, loud noises, imagined supernatural beings in younger children and fear of animals among girls and all non-white groups. CONCLUSIONS: Although fears are only labelled as phobias when they impair functioning and interfere with life, they can cause personal distress to children and also can interfere with their daily activities. Children's fears differ in nature across different ethnic groups. Culturally mediated beliefs, values and traditions may play a role in their expression.

Parenting support and PTSD in children of a war zone.

BACKGROUND: The protective role of parenting factors on the mental well-being of children exposed to war trauma remains an under-researched area. AIM: To establish the relationship between perceived positive parenting support and post-traumatic stress disorder (PTSD) symptoms in children exposed to war trauma. METHODS: A random sample of 412 children aged 12-16 years was selected from the Gaza Strip and was assessed using the Gaza Traumatic Events Checklist (GTEC), the SCID (DSM-IV) and the Perceived Parenting Support Scale (PPSS). RESULTS: Palestinian children were exposed to different types of war-traumatic events. The number of exposed traumatic events was independently associated with the severity of post-traumatic symptoms scores or the diagnosis of PTSD, while perceived parenting support was found to act as a protective factor in this association. CONCLUSIONS: Interventions in war zones need to ensure the minimal possible disruption to communities and family units, and to involve parents in preventive or treatment programmes for children exposed to trauma.

Experience of Self-Harm and Its Treatment in Looked-After Young People: An Interpretative Phenomenological Analysis.

We report the first Interpretative Phenomenological Analysis examination of self-harm and experience of clinical services in young people in the public care system. Qualitative interviews with 24 looked-after young people were completed. Prevalent themes were 1) Changes in care placement, 2) Feelings of anger, 3) Not wanting/feeling able to talk, 4) Developing coping techniques, 5) Clinical services: A relational mixed bag (subthemes: feeling (i) patronized, not listened to, (ii) nothing being done, (iii) comfortable/able to talk). Placement change and anger were highly salient to self-harm in this group and experiences of clinical services depended on individual relationships with clinicians. Implications include increasing compassion in therapeutic relationships, recognizing and managing emotional dysregulation, and increasing support during placement changes.

Cross-cultural measurement invariance of the Revised Child Anxiety and Depression Scale across 11 world-wide societies.

BACKGROUND: In order to compare estimates by one assessment scale across various cultures/ethnic groups, an important aspect that needs to be demonstrated is that its construct across these groups is invariant when measured using a similar and simultaneous approach (i.e., demonstrated cross-cultural measurement invariance). One of the methods for evaluating measurement invariance is testing for differential item functioning (DIF), which assesses whether different groups respond differently to particular items. The aim of this study was to evaluate the cross-cultural measurement invariance of the Revised Child Anxiety and Depression Scale (RCADS) in societies with different socioeconomic, cultural, and religious backgrounds. METHODS: The study was organised by the International Child Mental Health Study Group. Self-reported data were collected from adolescents residing in 11 countries: Brazil, Bulgaria, Croatia, Indonesia, Montenegro, Nigeria, Palestinian Territories, the Philippines, Portugal, Romania and Serbia. The multiple-indicators multiple-causes model was used to test the RCADS items for DIF across the countries. RESULTS: Ten items exhibited DIF considering all cross-country comparisons. Only one or two items were flagged with DIF in the head-to-head comparisons, while there were three to five items flagged with DIF, when one country was compared with the others. Even with all cross-culturally non-invariant items removed from nine language versions tested, the original factor model representing six anxiety and depressive symptoms subscales was not significantly violated. CONCLUSIONS: There is clear evidence that relatively small number of the RCADS items is non-invariant, especially when comparing two different cultural/ethnic groups, which indicates on its sound cross-cultural validity and suitability for cross-cultural comparisons in adolescent anxiety and depressive symptoms.

Uncovering key patterns in self-harm in adolescents: Sequence analysis using the Card Sort Task for Self-harm (CaTS).

BACKGROUND: Self-harm is a significant clinical issue in adolescence. There is little research on the interplay of key factors in the months, weeks, days and hours leading to self-harm. We developed the Card Sort Task for Self-harm (CaTS) to investigate the pattern of thoughts, feelings, events and behaviours leading to self-harm. METHODS: Forty-five young people (aged 13-21 years) with recent repeated self-harm completed the CaTS to describe their first ever/most recent self-harm episode. Lag sequential analysis determined significant transitions in factors leading to self-harm (presented in state transition diagrams). RESULTS: A significant sequential structure to the card sequences produced was observed demonstrating similarities and important differences in antecedents to first and most recent self-harm. Life-events were distal in the self-harm pathway and more heterogeneous. Of significant clinical concern was that the wish to die and hopelessness emerged as important antecedents in the most recent episode. First ever self-harm was associated with feeling better afterward, but this disappeared for the most recent episode. LIMITATIONS: Larger sample sizes are necessary to examine longer chains of sequences and differences in genders, age and type of self-harm. The sample was self-selected with 53% having experience of living in care. CONCLUSIONS: The CaTs offers a systematic approach to understanding the dynamic interplay of factors that lead to self-harm in young people. It offers a method to target key points for intervention in the self-harm pathway. Crucially the factors most proximal to self-harm (negative emotions, impulsivity and access to means) are modifiable with existing clinical interventions.

The effect of aerobic exercise in the maintenance treatment of depression.

We investigated the efficacy of aerobic exercise alongside antidepressant medication as an adjuvant maintenance treatment for depression. Fifty patients in remission were randomly assigned to either medication only or medication plus exercise. Assessment of psychopathology was made at 6-weekly intervals (for 24 weeks) using the Hamilton Rating Scale for Depression. The medication-plus-exercise group showed significantly more improvement at 12 and 24 weeks than the medication-only group. This study adds to a growing evidence base that suggests aerobic exercise is worthy of further development in the treatment of depressive disorders.

Exposure to war traumatic experiences, post-traumatic stress disorder and post-traumatic growth among nurses in Gaza.

ACCESSIBLE SUMMARY: What is known on the subject? This study builds on existing research on war-related factors that may affect health-care staff by particularly focusing on trauma exposure in both professional and everyday life, as well as on correlates of later positive psychological changes. What this paper adds to existing knowledge? It shows that one in five nursing staff working in Gaza experienced post-traumatic stress symptoms within the clinical range, 2 years after an incursion on Gaza and after being exposed to substantial trauma during this period. Participants appeared to develop a variety of post-traumatic growth responses following trauma exposure. Although nurses experienced traumatic events both as civilians and in their health-care capacity, personal exposure was strongly associated with PTSD symptoms. What are the implications for practice? Support to nursing and other health-care professionals in war situations should entail different levels, remain available well after an acute conflict, and take into consideration both personal and practice-related traumatic events. Mental health nursing practitioners can play a pivotal role in this. AIM: To establish the association between war traumatic experiences, post-traumatic stress disorder (PTSD) symptoms and post-traumatic growth among nurses in the Gaza Strip, 2 years after an incursion on Gaza, and during a period of ongoing trauma exposure. This study builds on existing evidence by considering exposure to personal and work-related traumatic events, and on factors associated with later positive psychological adaptation. METHODS: The sample consisted of 274 randomly selected nurses in Gaza who completed the Gaza Traumatic Events Checklist, PTSD Checklist, and Posttraumatic Growth Inventory. RESULTS: Of the nurses, 19.7% reported full PTSD. There was a significant relationship between traumatic events and PTSD scores; as well as between community-related traumatic events and post-traumatic growth. Participants reported a range of traumatic events, but PTSD and post-traumatic growth scores were more strongly associated with community rather than work-related traumas. DISCUSSION: Nursing professionals experienced high levels of distress 2 years following an acute period of conflict, both as civilians and in their health-care capacity. IMPLICATIONS FOR PRACTICE: There is need for different levels of support for health-care staff in war-affected areas. Mental health nursing professionals have a central role in training, counselling and support to other health-care colleagues.

Does the Strengths and Difficulties Questionnaire - self report yield invariant measurements across different nations? Data from the International Child Mental Health Study Group.

AIMS: This study evaluated the measurement invariance of the strengths and difficulties questionnaire (SDQ) self-report among adolescents from seven different nations. METHODS: Data for 2367 adolescents, aged 13-18 years, from India, Indonesia, Nigeria, Serbia, Turkey, Bulgaria and Croatia were available for a series of factor analyses. RESULTS: The five-factor model including original SDQ scales emotional symptoms, conduct problems, hyperactivity-inattention problems, peer problems and prosocial behaviour generated inadequate fit degree in all countries. A bifactor model with three factors (i.e., externalising, internalising and prosocial) and one general problem factor yielded adequate degree of fit in India, Nigeria, Turkey and Croatia. The prosocial behaviour, emotional symptoms and conduct problems factor were found to be common for all nations. However, originally proposed items loaded saliently on other factors besides the proposed ones or only some of them corresponded to proposed factors in all seven countries. CONCLUSIONS: Due to the lack of a common acceptable model across all countries, namely the same numbers of factors (i.e., dimensional invariance), it was not possible to perform the metric and scalar invariance test, what indicates that the SDQ self-report models tested lack appropriate measurement invariance across adolescents from these seven nations and it needs to be revised for cross-country comparisons.

Case reports of autism with interstitial deletion of chromosome 17 (p11.2 p11.2) and monosomy of chromosome 5 (5pter-->5p15.3).

Two cases of autism and autosomal chromosome abnormalities are reported: a 14-year-old boy with interstitial deletion of chromosome 17 and a 19-year-old man with an unbalanced translocation of chromosome 5, resulting in monosomy for part of the short arm (5pter-->5p15.3). The possible implications for research into the aetiology of autism are discussed.

Psychosocial functioning of homeless children.

OBJECTIVE: To investigate the psychosocial characteristics of homeless children and their parents. METHOD: Homeless families were assessed within 2 weeks of admission to seven hostels and were compared with a group of housed families matched for socioeconomic status. Measures included a semistructured interview, the General Health Questionnaire (GHQ), the interview Schedule for Social Interaction, the Child Behavior Checklist (CBCL), the Communication domain of the Vineland Adaptive Behavior Scales, and height and weight percentiles. The sample consisted of 113 homeless families (249 children aged 2 through 16 years) and 29 comparison families (83 children). RESULTS: Homeless families primarily consisted of single mothers and an average of two children, who had become homeless because of domestic violence (56%) or violence from neighbors (29%). Homeless mothers reported high rates of previous abuse (45%) and current psychiatric morbidity (49% caseness on the GHQ) and poor social support networks compared with housed controls. Homeless children were more likely to have histories of abuse, living in care, and being on the at-risk child protection register and less likely to have attended school or a preschool/day-care center since admission to the hostel. They also had delayed communication and higher CBCL scores. Maternal GHQ scores best predicted CBCL caseness. CONCLUSIONS: Homeless mothers and children have high rates of psychosocial morbidity, which are related to multiple risk factors and chronic adversities. Their complex needs should be best met by specialized and coordinated health, social, and educational services.

Urinary levels of neopterin and biopterin in autism.

The pterins, neopterin and biopterin, occur naturally in body fluids including urine. It is well established that increased neopterin levels are associated with activation of the cellular immune system and that reduced biopterins are essential for neurotransmitter synthesis. It has been suggested that some autistic children may be suffering from an autoimmune disorder. To investigate this further we performed high performance liquid chromatography analyses of urinary pterins in a group of pre-school autistic children, their siblings and age-matched control children. Both urinary neopterin and biopterin were raised in the autistic children compared to controls and the siblings showed intermediate values. This supports the possible involvement of cell-mediated immunity in the aetiology of autism.

A randomised controlled out-patient trial of cognitive-behavioural treatment for children and adolescents with depression: 9-month follow-up.

Nine-month outcome data of a randomized controlled out-patient trial of cognitive-behavioural treatment (CBT) for children and adolescents with depression are presented. CBT was compared with a non-focussed intervention (NFI) in 56 subjects. At 9 months after thr termination of the trial, 21 children (37.5%) fulfilled criteria for a psychiatric disorder (DSM-III-R), out of whom 15 (26.8%) had a depressive illness. However, 25 subjects (45%) reported depressive symptoms of significant severity to suggest a depressive episode during the previous 9-month period. Both treatment groups maintained a significant improvement on all psychosocial measures since the post-treatment assessment. No significant treatment effect was established. Low self-esteem at the time of referral, predicted presence of psychiatric disorder, and child-reported scores of depressive symptoms and low self-esteem at follow-up. The research and clinical implications for the treatment of depressive disorders in young life are discussed.

The path to care in autism: is it better now?

Parents of children with autism often report problems associated with obtaining a diagnosis of their child's condition, family support, information, and appropriate services. To evaluate any changes in the situation over the last two decades, the families of all members of the West Midlands Autistic Society, age 19 years and below, were asked to fill in a questionnaire that covered aspects of detection, diagnosis, help and information received, and educational provision. Responses were obtained from 127 families, the children of whom formed an older group ages 10 years and above (n = 67) and a younger group ages 9 years and below (n = 61). Findings show that there have been improvements for the younger group in some areas, such as earlier referral, diagnosis, and statementing. However, the situation with respect to advice given by professionals and the support and provision available after referral is still much the same as that experienced by families of the older group of children. Many difficulties and hurdles remain which hinder parents and children on the path to care in autism.

Pattern of semantic errors in autism: a brief research report.

Semantic or vocabulary errors were measured among children with autism and mild learning disability and children with mild learning disability only (six children of 7.9-8.7 years in each group), testing the hypothesis that these were common in both groups. Different variables were investigated such as breadth of vocabulary and number of vocabulary errors, type of paraphasias, and mechanisms used to name the meanings that children were not aware of or could not recall, and the particular meanings that were difficult for each group. Preliminary findings showed that vocabulary errors were similar in both groups, except under-extension, which was not used by the autism group. Children with autism tended to use all mechanisms in order to name something they did not know and to focus on parts of the object in order to name it, while unknown words were similar in both groups.

Post traumatic stress disorder reactions in children of war: a longitudinal study.

OBJECTIVE: To establish rates of posttraumatic stress disorder (PTSD) reactions and general mental health problems in children who had experienced war trauma. METHOD: A longitudinal study in the Gaza strip with 234 children aged 7 to 12 years, who had experienced war conflict, at 1 year after the initial assessment, that is, during the peace process. Children completed the Child Post Traumatic Stress Reaction Index (CPTS-RI), while the Rutter A2 and B2 Scales were completed by parents and teachers. RESULTS: The rate of children who reported moderate to severe PTSD reactions at follow-up had decreased from 40.6% (N = 102) to 10.0% (N = 74). 49 children (20.9%) were rated above the cut-off for mental health problems on the Rutter A2 (parent) Scales, and 74 children (31.8%) were above the cut-off on the Rutter B2 (teacher) Scales. The total scores on all three measures had significantly decreased during the 1-year period. The total CPTS-RI score at follow-up was best predicted by the number of traumatic experiences recalled at the first assessment. CONCLUSIONS: PTSD reactions tend to decrease in the absence of further stressors, although a substantial proportion of children still present with a range of emotional and behavioral problems. Cumulative previous experience of war trauma constitutes a risk factor for continuing PTSD symptoms.

Child mental health problems in Arab children: application of the strengths and difficulties questionnaire.

AIM: This study aimed at establishing the mental health profile among 322 Arab children living in the Gaza strip. METHOD: Children were selected in four age bands, i.e. 3, 6, 11 and 16 years of age. The relevant forms of the Strengths and Difficulties Questionnaire (SDQ) was completed by parents, teachers and 16-year-olds. RESULTS: Factor analyses of the parent-related questionnaires identified similar general factors as in the UK-based studies of validating the SDQ. Certain items did not load as highly on the general factors, i.e. distractability, feeling scared, feeling unhappy, stealing, and being picked or bullied. Emotional problems items were rated differently in the pre-school group (aches, nervousness-clinging, worries) than in previous studies. Using previous optimal cut-off scores, parent SDQs revealed higher rates of children with emotional and conduct problems falling above the 90th centile established in the UK sample, but lower rates according to self-report SDQs by 16-year-olds. CONCLUSIONS: Western categories of mental health problems did not clearly emerge from the factor analysis. The main difference from western epidemiological studies appeared to operate in parents' perceptions of emotional problems in pre-school children. The SDQ is very promising as a screening measure or rating scale in different cultural populations. However, future research should identify and establish indigenously meaningful constructs within this population and culture, and subsequently revise measures of child mental health problems.

Mental health problems and social supports among homeless mothers and children victims of domestic and community violence.

BACKGROUND: Children and mothers who have suffered domestic or neighbourhood violence constitute a high risk group, although it has not been clear whether their mental health needs are specifically related to the type of violence. This paper reports on the prevalence of mental health problems in homeless parents and children who have experienced domestic and neighbourhood violence and their access to social support networks. METHODS: Three groups of families who had become homeless were compared: those experiencing domestic violence (48 with 75 children), victims of neighbourhood violence (14 with 29 children), and those who became homeless for other reasons (31 with 54 children). Mothers completed a service use semi-structured interview, the Strengths and Difficulties Questionnaire, the General Health Questionnaire, the Family Support Scales, and the SF-36 Health Status Questionnaire. RESULTS: Levels of psychiatric morbidity were high in the group experiencing domestic violence (35.7% in children and 21.9% in mothers) and higher still in those who were victims of neighbourhood violence (52.2% in children and 50% in mothers). Levels of social support were found to be an important factor, particularly in relation to professional support and support from other family members, as they predicted both child and maternal psychopathology. CONCLUSIONS: Mental health interventions for victims of domestic and neighbourhood violence should be integrated with community programmes of social reintegration. Mental health professionals should work in close collaboration with Housing Departments, Social Services, Education and the Police.