Christopher R. Thomas

THE PREVALENCE OF MENTAL ILLNESS IN PRISON

Over the last decade state prisons have experienced unprecedented growth and many demographic changes. At the same time, courts are requiring states to provide mental health screening and treatment to prisoners. Findings from recent studies indicate that the prevalence of mental illness is higher in prisons than in the community, and comorbidity is common. Our ability to generalize from these studies is limited, however, because of major shifts in the demographic mix in prisons during the past decade. New studies on the prevalence of mental illness in prisons, which consider these recent changes would help planners allocate funds and staff to more effectively meet the needs of these individuals.

Evidence for developmentally based diagnoses of oppositional defiant disorder and conduct disorder

This paper compares the validity of DSM-III-R diagnoses of oppositional defiant disorder (ODD) and conduct disorder (CD) and an alternative option which is subdivided into three levels according to developmental sequence and severity: modified oppositional disorder (MODD), intermediate CD (ICD), and advanced CD (ACD). Using a sample of 177 boys followed over 3 years, both the DSM-III-R and the alternative diagnostic constructs are evaluated on three criteria: symptom discriminative validity, and diagnostic external and predictive validity. Most DSM-III-R ODD and CD symptoms discriminated between ODD and CD, but exceptions are noted. Additional analyses demonstrated considerable overlap among DSM-III-R oppositional symptoms. The majority of the symptoms proposed for the alternative option could be assigned to a specific level based on acceptable symptom discrimination. External validity lent support to the distinctions between DSM-III-R ODD and CD, and between MODD, ICD, and ACD. MODD was a better predictor than ODD of which boys received a later diagnosis of CD. Suggestions are made for the inclusion and exclusion of symptoms for developmentally based diagnoses of oppositional and conduct disorders.

PSYCHOLOGICAL PROBLEMS REPORTED BY YOUNG ADULTS WHO WERE BURNED AS CHILDREN

This study assessed long-term psychosocial sequelae of young adult pediatric burn survivors. Subjects were 101 young adults (43 females and 58 males) between the ages of 18 and 28 years who were at least 2 years (average, 14 years) postburn at least 30% TBSA (mean = 54 +/- 20%). Educational status was 25% high school dropouts, 28% high school graduation only, 32% some college, and 5% completed college. Seventy-seven percent either worked or attended school; 28% had had a long-term partner. When assessed by Achenbachs Young Adult Self-Report (YASR) scale and compared with its published reference group, the males reported differences only in the somatic complaints, but the females endorsed significantly more externalizing and total problems, specifically withdrawn behaviors, somatic complaints, thought problems, aggressive behavior, and delinquent behavior. Despite these problems suffered by some female pediatric burn survivors, the overall outcome revealed that most pediatric burn survivors are making the transition into adulthood with minimal unexpected difficulty.

Measuring the quality of life of youth with facial differences.

Objective: To describe the Facial Differences Module of the Youth Quality of Life Instruments (YQOL-FD) and present results evaluating domain structure, internal consistency, reproducibility, validity, and respondent burden. Design: A multisite observational study of youth aged 11 to 18 years with acquired or congenital facial differences. Participants: Three hundred seven youth recruited through clinics at four U.S. sites and one U.K. site. Eligible youth were aged 11 to 18 years, had a noticeable facial difference, could read at the fifth-grade level, and, for youth with facial burns, were at least 2 years posttrauma. Measures: Included were the newly developed YQOL-FD, the generic Youth Quality of Life Instrument, the Childrens Depression Inventory, and demographics. Results: Principal components analysis showed five significant factors that closely matched the domain structure hypothesized a priori. Domain scores of the YQOL-FD showed acceptable internal consistency and reproducibility. Scores were more strongly correlated with the Childrens Depression Inventory score than with self-rating of health as predicted. All domain scores showed adequate discrimination among levels of general quality of life (Wilks λ = 0.84, p = .001). The median time to complete the module was 10 minutes. Discussion: The YQOL Facial Differences Module augmented information obtained from the generic YQOL measure by addressing specific concerns. The module was well received by youth and showed acceptable measurement properties for evaluating the perceived quality-of-life status of youth facial differences. Future use in longitudinal studies and clinical trials is anticipated to evaluate the ability to detect change.

Propranolol does not reduce risk for acute stress disorder in pediatric burn trauma

OBJECTIVE Acute stress disorder (ASD) can interfere with satisfactory recovery of children with severe burn injuries. Recent studies have found propranolol to be effective in reducing posttraumatic symptoms, but the benefits of this medication with ASD are unknown. Therefore, we hypothesized that individuals who were administered propranolol acutely would be less likely to develop ASD than those who were not. METHOD A review of electronic medical records was conducted on the children included in a previous blinded randomized-control trial, in which the participants received propranolol or no propranolol during the acute phase of recovery (first 30 days). These data were merged with electronic information regarding medication treatment for ASD. The psychologists and clinicians who had previously assessed for ASD for purposes of treating the childrens distress were blinded to who received propranolol and who did not. RESULTS There were 363 participants (232 boys, 131 girls) and the mean total body surface area was 56%. Of this sample, 22 participants had been previously diagnosed and treated for ASD, and 341 were in a non-ASD group. Eight percent of those children who received propranolol required treatment for ASD, whereas 5% of children who received no propranolol also required treatment for ASD. No statistically significant difference was noted. CONCLUSIONS Propranolol was not found to influence the risk for subsequent ASD. This finding is in contrast to the observed benefit of propranolol reported in other studies with different at risk populations. Further exploration is warranted to assess the possible long-term benefit on posttraumatic symptoms in pediatric burn survivor patients.

Prevalence of major psychiatric illness in young adults who were burned as children

Objective: To determine the prevalence of major psychiatric illness in a group of young adults who suffered significant burn injury as children. Method: A total of 101 persons (58 males, 43 females), aged 21 ± 2.6 years, 14.0 ± 5.4 years postburn of 54% ± 20% total body surface area, were assessed for serious past and present mental illness by using a Structured Clinical Interview (SCID) for Diagnostic and Statistical Manual of Mental Disorders, 4th Edition (DSM-IV) Axis I diagnoses. Results: The SCID findings demonstrated that the prevalence of any Axis I major mental illness was 45.5% for the past month (current) and 59.4% for lifetime. These rates of overall disorder and the rates for most specific disorders were significantly higher than those found in the US population of comparable age. Logistic regression was used to examine demographic and burn characteristics as predictors of current and lifetime psychiatric disorder within the burn survivor sample. The female gender was significantly associated with higher rates of any current disorder. Other demographic and burn characteristics were not significantly related to the overall prevalence of current or lifetime disorder. Only a small number of those with disorders reported any current mental health treatment. Conclusions: Significant burn injury as a child leads to an increased risk of developing a major mental illness. Young adults who suffered major burn injury as children should be screened for these illnesses to initiate appropriate treatment. TBSA = total body surface area; SCID = Structured Clinical Interview; NCS = National Comorbidity Survey; DIS = Diagnostic Interview Schedule; CIDI = Composite International Diagnostic Interview; PTSD = posttraumatic stress disorder.

Conducting School-Based Assessments of Child and Adolescent Behavior

Shapiro, Kratochwill, Introduction: Conducting a Multidimensional Behavioral Assessment. Skinner, Rhymer, McDaniel, Naturlaistic Direct Observation in Educational Settings. Hintze, Stoner, Bull, Analogue Assessment: Emotional/Behavioral Problems. McComas, Hoch, Mace, Functional Analysis. Cole, Marder, McCann, Self- Monitoring. Eckert, Dunn, Codding, Guiney, Self-Report: Rating Scale Measures. McConaughy, Self-Report: Child Clinical Interviews. Merrell, Informant Report: Rating Scale Measures. Busse, Beaver, Informant Report: Parent and Teacher Interviews. Castillo, Quintana, Zamarripa, Cultural and Linguistic Issues.

National Distribution of Child and Adolescent Psychiatrists

OBJECTIVE To describe the national distribution of child and adolescent psychiatrists by state, community, and youth population. METHOD Data on child and adolescent psychiatrists were compiled for states and counties and compared by state, county characteristics, number of youth, percentage of youth living in poverty, and child and adolescent psychiatry residents. RESULTS The number of child and adolescent psychiatrists per 100,000 youth varied greatly by state and county. Child and adolescent psychiatrists were significantly more likely to be located in metropolitan counties and counties with a low percentage of children living in poverty. The distribution of child and adolescent psychiatrists was not significantly related to the distribution of child and adolescent psychiatry residency training programs. CONCLUSIONS The shortage of child and adolescent psychiatrists is accentuated for nonmetropolitan areas and youth at greatest risk for mental disorders by the current pattern of distribution.

Treating thermally injured children suffering symptoms of acute stress with imipramine and fluoxetine: A randomized, double-blind study

INTRODUCTION For pediatric burn patients with the symptoms of acute stress disorder (ASD) a first line medication is not widely agreed upon. A prospective, randomized, placebo controlled, double-blind design was used to test the efficacy of imipramine and fluoxetine. METHOD Patients 4-18 years of age with symptoms of ASD were randomized to 1 of 3 groups: imipramine, fluoxetine, or placebo for 1 week. Daily imipramine dose was 1mg/kg, with the maximum dose being 100mg. Daily fluoxetine dose was 5mg for children weighing >or=40 kg; 10mg for those weighing between 40 and 60 kg; 20mg for those weighing >60 kg. RESULTS Sixty participants, 16 females and 44 males, had an average body surface area burn of 53% (S.D.=18) and average age of 11 years (S.D.=4). Imipramine subjects received an average daily dose of 1.00+/-0.29 mg/kg. Fluoxetine subjects received an average daily dose of 0.29+/-0.16 mg/kg. Between group differences were not detected. Fifty-five percent responded positively to placebo; 60% responded positively to imipramine; and 72% responded positively to fluoxetine. CONCLUSION Within the parameters of this study design and sample, placebo was statistically as effective as either drug in treating symptoms of ASD.

A Double-Blind Study of the Analgesic Efficacy of Oral Transmucosal Fentanyl Citrate and Oral Morphine in Pediatric Patients Undergoing Burn Dressing Change and Tubbing

Burn wound care is extremely painful. The pain leads to added anxiety and therefore a distressing treatment that can negatively impact healing. Pain and anxiety management with oral transmucosal fentanyl citrate was compared with this institutions standard procedural pain medication, morphine. With a double-blinded, reverse crossover, time-randomized, and placebo-controlled design, the efficacy of morphine and fentanyl citrate was assessed with patients undergoing two consecutive days of tubbing. Pain and anxiety was assessed before, during, and after the tubbing procedure using the Faces Pain Rating Scale (Whaley and Wong, 1987) and the Fear Thermometer (Silverman and Kurtines, 1996). Data were analyzed with repeated measures analysis of variance. Pain and anxiety appeared better managed with fentanyl citrate. Generalization is limited by small sample size, yet findings warrant additional investigation.