David Dossetor

Quality of life of survivors of pediatric intensive care.

Objective Measuring outcome in pediatric intensive care is necessary to equate the high cost of treatment with benefits to the patient. Although mortality rates and morbidity are relatively insensitive measures of the benefits of treatment, quality of life measurement gives insight into the long-term outcomes. The aim of this study was to investigate the long-term quality of life outcome of children admitted to a pediatric intensive care unit. Design Prospective survey. Setting A 13-bed pediatric intensive care unit in a university-affiliated, tertiary referral children’s hospital. Patients Patients were 432 children discharged from the pediatric intensive care unit between May 1992 and April 1994. Interventions Quality of life was measured by using the Royal Alexandra Hospital for Children Measure of Function. The scale has two components, the first part completed by the clinician after parent interview and the second part completed separately by the parent. Measurements and Main Results Parents of 432 children were contacted between 3 and 24 months after discharge. Twenty-seven children (6.3%) had died after discharge from the pediatric intensive care unit; 59.3% (256) had scores indicating a normal quality of life, and 32.4% (140) had a fair quality of life with ongoing health, social, or cognitive problems requiring some intervention. Two percent of survivors (nine children) had scores indicating a poor quality of life as they had continued to experience significant or disabling health problems requiring hospitalization or the equivalent. Predictors of poor quality of life included presence of comorbidities, increased length of stay, and a diagnostic category of malignancy. Diagnostic categories of respiratory, trauma, and cardiac dysfunction were associated with a better outcome. Conclusions Our results indicate that the long-term outcome in terms of quality of life after admission to a pediatric intensive care unit is good or normal for the majority of surviving children. Those children with a poor outcome are likely to have significant comorbidities or a diagnosis of malignancy.

'All That Glitters Is Not Gold': Misdiagnosis of Psychosis in Pervasive Developmental Disorders — A Case Series:

The early literature established the validity of the distinction between early onset schizophrenia and autism. In the modern context of increasing recognition of pervasive developmental disorders (PDD) and a growing interest in very early onset schizophrenia and other childhood onset psychoses, this clinical distinction is often difficult to make. This article looks at problems arising from overdiagnosing psychosis in those with PDD. Four case examples of misattributed diagnosis of psychosis are described. The features that were mistaken for psychotic phenomena are described and explained and successfully treated in the context of a diagnosis of PDD. The article describes problems of reliability of ascertaining subjective mental phenomena and the range of mental phenomena that need to be recognized in PDD. The overlap of abnormal perceptions and cognitions in both these conditions is described with reference to the literature. It is evident that more needs to be done to improve diagnostic reliability of psychosis in PDD, by improving clinical awareness and research tools.

Use of risperidone in a paediatric population: an observational study.

Objective:  To evaluate the impact of risperidone on functional impairment in a paediatric sample and to document the range of adverse drug reactions.

Child and adolescent telepsychiatry in New South Wales: moving beyond clinical consultation

Objectives: Telepsychiatry has been demonstrated to be an effective and acceptable way to deliver psychiatry services to remote and rural areas. This paper describes the initial evaluation of the Child and Adolescent Psychological Telemedicine Outreach Service (CAPTOS) in New South Wales and the changes made to the service after the initial evaluation. Methods: The evaluation investigated patients’, rural clinicians’ and CAPTOS psychiatrists’ satisfaction with the quality of the service and the technology. Results: There were 136 rural families, 20 rural clinicians and eight psychiatrists. Overall, satisfaction was high with the rural families and clinicians being the most satisfied (95–99% very or mostly satisfied). CAPTOS psychiatrists felt that they were usually able to perform an adequate consultation (87%) but few (16%) felt the consultations were as satisfactory as a face to face consultation. Because of the initial evaluation, and the ongoing collaboration with rural clinicians, further services were developed using the technology and the developing professional networks. These initiatives included telenursing, professional skills development, sabbaticals for rural clinicians and a clinical skills workshop for rural clinicians. Conclusions: This study confirms telepsychiatry as a useful service for remote and rural children and families. The results also suggest some reasons why urban clinicians show the least enthusiasm for the service. Ways of addressing some of the limitations of the service are suggested, and the expansion of CAPTOS to meet the needs of rural clinicians is discussed.

The presentation of aggressive children and adolescents to emergency departments in Western Sydney

Aim:  To examine the utilization characteristics of children and adolescents with aggression presenting to emergency departments (ED) in Western Sydney.

The Association Between Social Skills and Mental Health in School-Aged Children with Autism Spectrum Disorder, With and Without Intellectual Disability

Autism Spectrum Disorder (ASD) is associated with social skills deficits and co-occurring mental health difficulties. ASD frequently co-occurs with Intellectual Disability (ID). There is scant literature exploring the association between social skills and mental health in children with ASD, with or without ID. Participants were 292 children aged six to 13 with ASD (217 without ID; 76 with Mild ID). Parents and teachers rated social skills and mental health using standardised questionnaires. Greater mental health difficulties were associated with greater social responsiveness difficulties and poorer social skills across the sample. Effect sizes were large. Social skills explained a significant proportion of the variance in mental health scores across the sample. The study has important implications for treatment and future research.

Developmental neuropsychiatry: A new model of psychiatry for young people with and without intellectual disability

Deinstitutionalization of young people with intellectual disability means that they are now cared for by families and served by community-based professionals. Normalization, which has been the guiding philosophy for this re-integration, has challenged child psychiatry to accept its responsibility for the mental health of this special needs group. It is argued that this group, with its special mental health needs, has had an influence on the conceptual framework of child psychiatry, particularly our understanding of development. This article examines the influence of the psychiatry of intellectual disability on child psychiatry and the influence of child psychiatry on the understanding of the mental health needs of those with intellectual disability. In particular, the management of young people with intellectual disability has required child psychiatry to expand its understanding of a biopsychosocial approach. Some of the resulting changes and challenges are presented to illustrate the benefits for both child psychiatry and the psychiatry of intellectual disability. The interaction of different conceptual biases has led to a new and broader conceptual spectrum of developmental neuropsychiatry . Developmental neuropsychiatry recognizes the need to integrate social science and preventative strategies at one end of the spectrum, with the genetics, molecular biology of human behaviour and targeted pharmacology at the other, and consider the developmental and interactive nature of such models. This article argues that this emerging, dynamic and broader conceptual framework of developmental neuropsychiatry enhances our understanding of the child mental health of all children. The article looks at some of the implications for assessment, diagnosis and treatment. As mental health needs become a greater public health priority, the advances in basic sciences will reinvigorate this medical specialty and training programmes will need to reflect these.

A Framework for Developing a Curriculum Regarding Autism Spectrum Disorders for Primary Care Providers.

INTRODUCTION The prevalence of Autism Spectrum Disorders (ASDs) has increased and varies across age groups. Thus there is an increasing need for educational opportunities for General Practitioners (GPs) and other Primary Care providers to help in early identification and referral to specialist services. An earlier survey of GPs in New South Wales (Australia) demonstrated two broad domains for educational activities: (1) a general knowledge (important for early identification and referral) and (2) surveillance (important for ongoing management). AIM To seek further evidence to these domains and synthesize the important contents for educational programs for GPs. MATERIALS AND METHODS We conducted a (1) Confirmatory Factor Analysis (CFA) on our original survey data and (2) systematic review of the literature to identify important educational topics, using a life cycle approach. RESULTS CFA and literature review support theoretical framework of two domains. Alerts and red flags for ASDs, knowledge of simple surveillance tools, communication of diagnosis with parents, referral pathways particularly to speech pathologists before a formal diagnosis is confirmed, and appreciation of vulnerabilities for identifying supports were important in the general knowledge domain, while supporting the families through transition points such as from pre-school to school entry, secondary school and adolescence, role of psychopharmacology such as medications for sleep issues, and for common co-morbidities of anxiety were important in the surveillance dimension. CONCLUSION GP supervisors and medical and nursing educators can use findings from this paper for developing structured learning activities for training primary health care workforce regarding ASDs.

A Pilot Study for Understanding the Perceptions of Australian General Practitioners Regarding Psychopharmacology for Children With Autism Spectrum Disorders.

Background: General practitioners (GPs) are increasing involved in the care of children with autism spectrum disorders (ASDs), and prescribe and/or manage psychotropic medications for these children. Few published reports of perceptions of GPs regarding use of these medications exist in the literature. Objective: Qualitative analysis of comments by 177 GPs regarding psychopharmacology use in children with ASDs. Methods: A postal questionnaire survey containing both close- and open-ended questions was conducted in New South Wales, Australia. Results: Respondent GPs were more likely to be females graduated from Australian medical schools and reported an interest either in child or in mental health. The respondents demonstrated good understanding of the issues surrounding psychopharmacology use in children with ASD based on contemporary literature on this topic. The main themes included concerns regarding medication safety, evidence for their use, and role of these medications as an adjuvant to behavior management. GPs reported a lack of experience of these medications, and would often prescribe only under the supervision of specialists. GPs with greater confidence and involvement with children of ASDs prescribed more medications; whereas GP reporting more concerns with regard to medications prescribed less. Conclusion: Respondent GPs have good understanding of psychotropic medications but need support from specialists for managing these medications in children with ASDs. Future larger studies should explore the utility of collaborative models of care for GPs to work in close partnerships with specialists.

The Developmental Psychiatry Manifesto: A Commentary

I C O M M E N D C H I L D mental health clinicians to take note of Jeremy Turk’s bold position on developmental psychiatry. Although based on personal clinical assertion, Dr Turk’s views are representative of the significant minority of child mental health clinicians who have special training, experience and interest in children and young people with intellectual (learning) disability, or mental retardation. Our specialty should do more to recognize, accept and provide services for young people with intellectual disability. I wish to broaden the context of the manifesto and look at some wider implications for child mental health. Within the ‘world’ of intellectual disability in the 1980s and 1990s, normalization and de-institutionalization were major events. Moving young people with intellectual disability from a life in hospital back wards into community homes may have affected a relatively small number of children. However, it was important politically and sociologically. It recognized the stigma and handicap that can arise from alienation from personal relationships, and the benefits of social and community access that ‘mainstream’ populations take for granted. A minority of mainstream child mental health training schemes and services have responded to this normalization process. Few training schemes give due attention to the major developmental and mental health problems of young people with intellectual disability. How many services triage cases on the basis of IQ, excluding those with intellectual disability? Accordingly, child mental health services have not adequately recognized the rights of equity of access of this group of children. These children need access to mainstream mental health services and such services need to maintain specific expertise. This is a significant challenge. It has been estimated that the