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Paediatric functional gastrointestinal disorders (P-FGIDs) are common, affecting up to 25% of children worldwide. They are characterised by chronic abdominal pain and/or altered bowel habits without an underlying disease pathology. P-FGIDs are often associated with co-occurring anxiety and depression across all ages and treating P-FGIDs may provide an opportunity to develop a young person's wider emotion regulation capacities. Using a fictitious case vignette, we outline the range of psychosocial and biomedical treatments for the disorder and the need for an integrated and holistic approach. We propose that by intervening early and enabling children to be curious about, rather than fearful of, their bodily sensations, clinicians may be able to alter harmful illness trajectories in both pain and psychiatric domains.
Waiting lists for children and young people with mental health problems are at an all-time high. Almost the only policies proposed to deal with this situation involve increasing the number of mental health professionals. Little attention is given to dealing with the underlying causative stresses, of which poverty is easily the most pervasive. It is suggested that unless levels of poverty are reduced, the rates of psychiatric disorders will not change. As psychiatrists, we need to become much more active in pressing for action over child poverty.
The school–vacation cycle may have impacts on the psychological states of adolescents. However, little evidence illustrates how transition from school to vacation impacts students’ psychological states (e.g. depression and anxiety).
Aims
To explore the changing patterns of depression and anxiety symptoms among adolescent students within a school–vacation transition and to provide insights for prevention or intervention targets.
Method
Social demographic data and depression and anxiety symptoms were measured from 1380 adolescent students during the school year (age: 13.8 ± 0.88) and 1100 students during the summer vacation (age: 14.2 ± 0.93) in China. Multilevel mixed-effect models were used to examine the changes in depression and anxiety levels and the associated influencing factors. Network analysis was used to explore the symptom network structures of depression and anxiety during school and vacation.
Results
Depression and anxiety symptoms significantly decreased during the vacation compared to the school period. Being female, higher age and with lower mother's educational level were identified as longitudinal risk factors. Interaction effects were found between group (school versus vacation) and the father's educational level as well as grade. Network analyses demonstrated that the anxiety symptoms, including ‘Nervous’, ‘Control worry’ and ‘Relax’ were the most central symptoms at both times. Psychomotor disturbance, including ‘Restless’, ‘Nervous’ and ‘Motor’, bridged depression and anxiety symptoms. The central and bridge symptoms showed variation across the school vacation.
Conclusions
The school–vacation transition had an impact on students’ depression and anxiety symptoms. Prevention and intervention strategies for adolescents’ depression and anxiety during school and vacation periods should be differentially developed.
Intergenerational transmission of mental disorders has been well established, but it is unclear whether exposure to a child's mental disorder increases parents' subsequent risk of mental disorders.
Aims
We examined the association of mental disorders in children with their parents' subsequent mental disorders.
Method
In this population-based cohort study, we included all individuals with children born in Finland or Denmark in 1990–2010. Information about mental disorders was acquired from national registers. The follow-up period began when the parent's eldest child was 5 years old (for ICD-10 codes F10–F60) or 1 year old (for codes F70–F98) and ended on 31 December 2019 or when the parent received a mental disorder diagnosis, died, or emigrated from Finland or Denmark. The associations of mental disorders in children with their parents' subsequent mental disorders were examined using Cox proportional hazards models.
Results
The study cohort included 1 651 723 parents. In total, 248 328 women and 250 763 men had at least one child who had been diagnosed with a mental disorder. The risk of a parent receiving a mental disorder diagnosis was higher among those who had a child with a mental disorder compared with those who did not. For both parents, the hazard ratios were greatest in the first 6 months after the child's diagnosis (hazard ratio 2.04–2.54), followed by a subtle decline in the risk (after 2 years, the hazard ratio was 1.33–1.77).
Conclusion
Mental disorders in children are associated with a greater risk of subsequent mental disorders among their parents. Additional support is needed for parents whose children have been recently diagnosed with a mental disorder.
An improved understanding of the factors associated with self-harm in young people who die by suicide can inform suicide prevention measures.
Aims
To describe sociodemographic and clinical characteristics and service utilisation related to self-harm in a national sample of young people who died by suicide.
Method
We carried out a descriptive study of self-harm in a national consecutive case series (N = 544) of 10- to 19-year-olds who died by suicide over 3 years (2014–2016) in the UK as identified from national mortality data. Information was collected from coroner inquest hearings, child death investigations, criminal justice system and National Health Service serious incident reports.
Results
Almost half (49%) of these young people had harmed themselves at some point in their lives, a quarter (26%) in the 3 months before death. Girls were twice as likely as boys to have recent self-harm (40 v. 20%; P < 0.001). Compared to the no self-harm group, young people with recent self-harm were more likely to have a mental illness diagnosis (63 v. 23%; P < 0.001); misused alcohol (19 v. 9%; P = 0.07); experienced physical, sexual or emotional abuse (17 v. 3%; P < 0.01); and recent life adversity (95 v. 75%; P < 0.001). Furthermore, they were more likely to be in contact with mental health services (60 v. 10%), or emergency departments or general physicians for a mental health condition (52 v. 10%) in the 3 months before death.
Conclusions
Presentation to services in young people who self-harm is an important opportunity to intervene through comprehensive psychosocial assessment and treatment of underlying conditions.
Commonly occurring mental health disorders have been well studied in terms of epidemiology, presentation, risk factors and management. However, rare or uncommon mental health disorders and events are harder to study. One way to do this is active surveillance. This article summarises how the Royal College of Psychiatrists Child and Adolescent Psychiatry Surveillance System was developed, as well as the key studies that have used the system and their impact, to make the case for a wider international surveillance unit for child and adolescent psychiatry. Keeping this surveillance active in different populations across the globe will add to existing knowledge and understanding of these uncommon disorders and events. This will in turn help in developing better frameworks for the identification and management for these disorders and events. It will also facilitate the sharing of ideas regarding current methodology, ethics, the most appropriate means of evaluating units and their potential applications.
Discipline is a crucial aspect of parenting, shaping child development and behaviour. Time-out, a widely used disciplinary strategy with a strong evidence-base, has recently come under scrutiny with concerns about potential adverse effects on children's emotional development and attachment, particularly for those with a history of adversity.
Aims
To contribute critical empirical insights to the current controversy surrounding time-out by exploring the associations among time-out implementation, parent–child attachment and child mental health, and whether adversity exposure moderated these associations.
Method
This cross-sectional study utilised a nationally representative sample of 474 primary caregivers in Australia, with children aged 6–8 years, who completed an online survey. Measures included the Implementation of Time-out Scale, Adverse Life Experiences Scale, Primary Attachment Style Questionnaire, Strengths and Difficulties Questionnaire and Spence Child Anxiety Scale.
Results
Appropriately implemented time-out was associated with enhanced mental health and attachment, while inappropriate time-out correlated with adverse child outcomes. Exposure to adversity moderated the relationship between time-out implementation and child well-being, such that children exposed to adversity were most likely to experience attachment enhancement from appropriately implemented time-out.
Conclusions
Despite recent concerns of harm caused by time-out, particularly for children with a history of adversity, findings support the beneficial impact of time-out on child well-being and attachment when implemented in accordance with evidence-based parameters. Combatting misinformation and disseminating evidence-based time-out guidelines is crucial for promoting child well-being and attachment, especially for children who have experienced adversity.
There is evidence that social contagion plays a role in shaping the clinical presentation of some psychiatric symptoms, particularly affecting features that vary over time and culture. Some symptoms can increase so rapidly in prevalence that they become ‘epidemic’. The mechanism involves a spread through peers and/or the media. Within broader domains of psychopathology, this process draws from a ‘symptom pool’ that can determine which specific symptoms will appear. This article illustrates these mechanisms by focusing on non-suicidal self-injury (NSSI), a syndrome that has been subject to social contagion and whose prevalence may have increased among adolescents.
Various studies have highlighted the increased incidence and symptoms of depression and anxiety in paediatric cancer survivors (PCS). Yet no meta-analysis has focused on post-traumatic stress disorder (PTSD) or post-traumatic stress symptoms (PTSS) in PCS and their family nucleus.
Aims
To evaluate the overall risk of PTSD and severity of PTSS in PCS and their family nucleus. Secondary objectives include identifying potential risk factors of PTSD and high PTSS.
Method
We systematically searched PubMed, Embase and PsycINFO for studies comparing the risk of PTSD and PTSS severity among PCS, their family nucleus and non-cancer controls. PRISMA reporting guidelines were followed. Random effects meta-analyses and meta-regressions were conducted.
Results
From 1089 records, we included 21 studies. PCS have an increased risk of PTSD (risk ratio 2.36, 95% CI 1.37–4.06) and decreased PTSS severity (standardised mean difference −0.29, 95% CI −0.50 to −0.08). Subgroup analyses of other categorical study-level characteristics revealed that female PCS who were older at diagnosis and data collection had a significantly higher risk of PTSD. Meta-regression were insignificant. Family nucleus did not show a significantly increased risk of PTSD (risk ratio 1.13, 95% CI 0.59–5.00) and PTSS severity (standardised mean difference 0.53, 95% CI −0.00 to 1.06). Systematically reviewing studies on the family nucleus found that the majority reported a significantly increased risk of psychological trauma compared with the comparator. Lower education, income and social status were also risk factors.
Conclusions
Timely identification and interventions are imperative for policy makers and healthcare providers to prevent trauma from worsening in this population group.
An important change in ICD-11 is the lifespan approach, whereby previous child and adolescent disorders have been amalgamated with adult disorders. There have been changes in the definition/descriptions of neurodevelopmental and disruptive disorders, some of which may have an impact on service development.
Young people from racialised backgrounds are overrepresented in justice services. This study explored differences in community support offered to young people from racialised groups referred to a forensic child and adolescent mental health service.
Method
We compared support offered to 427 young people, according to five ethnic groups.
Results
Over 20% of young people referred were Black (compared with 14% of the local population) and 15.8% were Dual White and Black Heritage (compared with 4% of the local population). Odds ratios showed that Black and Dual Heritage groups were more frequently involved with youth offending services (Black: 2.59, Dual Heritage: 2.88), gangs services (Black: 4.31, Dual Heritage: 7.13) and have a national referral mechanism (Black: 3.61, Dual Heritage: 4.01) than their White peers, but were less often in mainstream education compared with their Asian peers (Black: 0.26, Dual Heritage: 0.29). Black (odds ratio 0.35) and Dual Heritage (odds ratio 0.40) young people were less frequently diagnosed with a neurodevelopmental disorder than their White peers.
Conclusions
Those from Black and Dual Heritage backgrounds were disproportionately disadvantaged.
This commentary reflects on two articles on consent in those under 18 years of age, known in law as ‘minors’. I consider why the language and landscape of the law in relation to consent in this age group can be alienating to psychiatrists, interrogate the legal complexities regarding consent in children and adolescents, refer to key aspects of relevant case law and end with practical suggestions that might improve clinical practice with cases that have the potential for legal complexity.
There are now hundreds of systematic reviews on attention deficit hyperactivity disorder (ADHD) of variable quality. To help navigate this literature, we have reviewed systematic reviews on any topic on ADHD.
Methods
We searched MEDLINE, PubMed, PsycINFO, Cochrane Library, and Web of Science and performed quality assessment according to the Joanna Briggs Institute Manual for Evidence Synthesis. A total of 231 systematic reviews and meta-analyses met the eligibility criteria.
Results
The prevalence of ADHD was 7.2% for children and adolescents and 2.5% for adults, though with major uncertainty due to methodological variation in the existing literature. There is evidence for both biological and social risk factors for ADHD, but this evidence is mostly correlational rather than causal due to confounding and reverse causality. There is strong evidence for the efficacy of pharmacological treatment on symptom reduction in the short-term, particularly for stimulants. However, there is limited evidence for the efficacy of pharmacotherapy in mitigating adverse life trajectories such as educational attainment, employment, substance abuse, injuries, suicides, crime, and comorbid mental and somatic conditions. Pharmacotherapy is linked with side effects like disturbed sleep, reduced appetite, and increased blood pressure, but less is known about potential adverse effects after long-term use. Evidence of the efficacy of nonpharmacological treatments is mixed.
Conclusions
Despite hundreds of systematic reviews on ADHD, key questions are still unanswered. Evidence gaps remain as to a more accurate prevalence of ADHD, whether documented risk factors are causal, the efficacy of nonpharmacological treatments on any outcomes, and pharmacotherapy in mitigating the adverse outcomes associated with ADHD.
John Bowlby's ‘Attachment and Loss’ trilogy set the scene for half a century of attachment research and theorising. This article picks out the key themes of his work – the attachment dynamic, the impact of trauma and life events, defensive exclusion, loss and bereavement, and internal working models – and points to their continuing relevance.
Multiaxial classification system development (organising important and relevant clinical factors under multiple headings or ‘axes’) has a long history stretching back to the 1940s. The World Health Organization supported the development of a multiaxial system of classification for children from the 1960s and in the 1990s produced a comprehensive multiaxial system which could be used with ICD-10. Using the multiaxial approach provides for an atheoretical framework that can integrate factors from within the child and the environmental influences on the child. This article presents a variety of ways in which the ICD-10 multiaxial framework can be extended from its classic usage to provide clinicians with valuable tools to assist in a biopsychosocial clinical assessment. Using the multiaxial system in an extended format allows a more comprehensive diagnosis and planning of treatments and is helpful in the training and teaching of juniors. It is also useful in evaluating responses to medication when it is combined with a chronological analysis and can provide other useful ways of integrating information relevant to understanding clinical cases.
Catatonia is a neuropsychiatric condition that causes disruption of movement, emotion, and behaviors. Children and adults with underlying psychiatric conditions are particularly susceptible to developing catatonia, which may result in medical and psychiatric complications. Although catatonia research has been growing at a rapid rate in the last 20 years, it continues to be met with inefficiencies in its diagnosis and incertitude in its treatment. In the pediatric population, catatonia is plagued by diagnostic overshadowing, where the catatonia is erroneously attributed to existing pathologies that lead to a prolonged disease state. This paper describes three pediatric patients with catatonia that fell victim to diagnostic overshadowing. More rigorous training and education are imperative to improve the efficient recognition and treatment of children with catatonia.
Trans-cranial magnetic stimulation (TMS) as a non-invasive method of altering brain activity (1) has widened the array of therapeutic options available for various psychiatric disorders.
Objectives
Trans-cranial Magnetic stimulation (TMS) as a non-invasive method of altering brain activity has widened the array of therapeutic options available for various psychiatric disorders. •A large number of studies have shown therapeutic benefits in a wide range of patient population with majority of studies in adults. •TMS is used increasingly for the treatment of child and adolescent depression. •Yet, the scarcity of studies and lack of published guidelines for this population is notable. •As TMS use is expanding in this population, an overview of the use of TMS in children and adolescents with depression may provide much needed and timely perspective on this neuropsychiatric intervention.
Methods
We searched all published studies using PubMed database, on TMS use in depressive disorders in children and adolescents. A total of 13 studies were found to have reported use of TMS in depression in children and adolescents.
Results
We found various case series, open label studies as well as sham controlled blind studies indicating that TMS has been effective in treating depression in children and adolescents. No significant side effects were found in our review.
Conclusions
Studies have shown that TMS is an effective treatment option for depressive disorders in children and adolescents. Initial studies look promising but implications in large pediatric population may be different and there is a need for more double blind, controlled trials with larger sample size.