Julia Gledhill

Child psychiatric disorder and relative age within school year: cross sectional survey of large population sample

Abstract Objective To test the hypothesis that younger children in a school year are at greater risk of emotional and behavioural problems. DesignCross sectional survey. Setting Community sample from England, Scotland, and Wales. Participants 10 438 British 5-15 year olds. Main outcome measures Total symptom scores on psychopathology questionnaires completed by parents, teachers, and 11-15 year olds; psychiatric diagnoses based on a clinical review of detailed interview data. Results Younger children in a school year were significantly more likely to have higher symptom scores and psychiatric disorder. The adjusted regression coefficients for relative age were 0.51 (95% confidence interval 0.36 to 0.65, P < 0.0001) according to teacher report and0.35 (0.23 to 0.47, P = 0.0001) for parental report. The adjusted odds ratio for psychiatric diagnoses for decreasing relative age was 1.14 (1.03 to 1.25, P = 0.009). The effect was evident acrossdifferent measures, raters, and age bands. Cross national comparisons supported a “relative age” explanation based on the disadvantages of immaturity rather than a “season of birth” explanation based on seasonal variation in biological risk. Conclusions The younger children in a school year are at slightly greater psychiatric risk than older children. Increased awareness by teachers of the relative age of their pupils and a more flexible approach to childrens progression through school might reduce the number of children with impairing psychiatric disorders in the general population.

Short-term psychiatric adjustment of children and their parents following meningococcal disease.

Objective: To assess short-term changes in child and parent psychiatric status following meningococcal disease. Design: Prospective cohort study; 3-month follow-up using parent, teacher, and child questionnaires. Setting: Hospital admissions to three pediatric intensive care units and 19 general pediatric wards. Patients: Sixty children aged 3–6 yrs, 60 mothers, and 45 fathers. Interventions: We administered measures of illness severity (Glasgow Meningococcal Septicaemia Prognostic Score, days in hospital) and psychiatric morbidity (Strengths and Difficulties Questionnaires, parent and teacher versions; Impact of Event scales; General Health Questionnaire-28). Measurements and Main Results: In children admitted to pediatric intensive care units, parental reports at 3-month follow-up showed a significant increase in emotional and hyperactivity symptoms and in related impairment; symptoms of posttraumatic stress disorder were present in four of 26 (15%) children >8 yrs old. Regarding the parents, 26 of 60 (43%) mothers in the total sample had questionnaire scores indicative of high risk for psychiatric disorder and 22 of 58 (48%) for posttraumatic stress disorder. In fathers there was high risk for psychiatric disorder in 11 of 45 (24%) and for posttraumatic stress disorder in 8 of 43 (19%). Severity of the childs physical condition on admission was significantly associated with hyperactivity and conduct symptoms at follow-up. Length of hospital admission was associated with psychiatric symptoms in the child and posttraumatic stress disorder symptoms in parents. There were also significant associations between psychiatric symptoms in children and parents. Conclusions: Admission of children to pediatric intensive care units for meningococcal disease is associated with an increase in and high levels of psychiatric and posttraumatic stress disorder symptoms in children and parents. Length of admission is associated with psychiatric symptoms in children and posttraumatic stress disorder symptoms in parents. Pediatric follow-up should explore psychiatric as well as physical sequelae in children and parents.

Surviving chronic physical illness: psychosocial outcome in adult life

Recent advances in physical treatments have changed the implications of receiving a diagnosis of chronic physical illness in childhood. Individuals with disorders such as diabetes, cystic fibrosis, renal failure, and cancer, who may previously have had a limited life expectancy are now surviving into adulthood. During childhood, chronic physical illness confers an increased risk of emotional and behavioural disorders,1 although the majority of children and families successfully adapt to the diagnosis. The increased likelihood of psychiatric disorder during childhood does not seem to be specific to the diagnostic category beyond those involving brain dysfunction,2 3 but reflects the difficulties inherent in living with a chronic illness. Children at greater risk are those with more severe physical disorder,4 and perhaps those with illnesses carrying a greater degree of life threat.5 The risk also varies with the stage of the illness. Adjustment disorders (emotional and/or behavioural symptoms clearly linked in onset to a stressful event and time limited in manifestation) are probably the most frequent psychiatric sequelae and are particularly common at the time of initial diagnosis and after changes in treatment have occurred. For example, psychological problems were reported in almost 60% of children at the time of starting dialysis. One year later, after stabilisation of their physical condition, the prevalence of disturbance was reduced to 21%.6 Similarly, 36% of 8–13 year olds with newly diagnosed insulin dependent diabetes mellitus developed an adjustment disorder (most commonly dominated by depressive symptoms) within the first three months of diagnosis; 50% had recovered within two months.7 While interest is frequently focused on the physical outcome of this group of children as they progress through adolescence into adult life, much less attention has been given to psychosocial outcome. How are they functioning emotionally and socially after their discharge from …

Training General Practitioners in the Identification and Management of Adolescent Depression within the Consultation: A Feasibility Study.

BACKGROUND Depressive disorders are common in adolescent general practice attenders. METHOD Adolescent attenders were screened/interviewed for depressive disorders, general practitioners (GPs) completed a checklist indicating recognition of psychopathology prior to and following GP training in the identification/management of adolescent depression. RESULTS One hundred and thirty consecutive adolescent attenders were screened before and 184 after training. Ten GPs completed the training. Psychiatric interviews with 38 adolescents with high depressive scores prior to and 44 following training identified 10 (26%) and 21 (48%), respectively, as clinically depressed. Sensitivity of GP identification improved from 2/10 (20%) to 9/21 (43%) without loss of specificity; predictive validity from 2/6 (33%) to 9/12 (75%). Adolescents interviewed appreciated the intervention. CONCLUSIONS Training GPs is feasible and may improve recognition of adolescent depression.

Does Season of Birth Matter? The Relationship between Age within the School Year (Season of Birth) and Educational Difficulties among a Representative General Population Sample of Children and Adolescents (Aged 5–15) in Great Britain

P working in the field of education have long been aware of the disadvantageous position that summer-born children (the youngest in the school year) may be placed in within the education system. In Britain the academic year begins in September, and there may be almost a year’s chronological age difference between the eldest (September birthday) and youngest (August birthday) children in the same class. There is evidence that, in this context, children born in the autumn term (September to December birthdays) perform better academically, relative to their class peers, than those born in the spring term (January to April birthdays), who in turn outperform those born in the summer term (May to August birthdays) (Russell and Startup, 1986). Summer-born children have been found more frequently than expected in the lower streams of junior schools (Jinks, 1964). A study of over 2,000 children attending fifty London primary schools revealed that the youngest children in the year (summer-born) were performing less well than their autumn-born classmates in reading at entry to junior school (aged 7, rising 8). Almost 33 per cent of summer-born pupils as compared with 19 per cent of autumn-born children obtained scores in the lowest quarter of the distribution. This discrepancy persisted throughout junior school, and a similar pattern was found for mathematics attainment (Mortimore et al., 1988). Additionally, a disproportionately high number of summer-born children are referred for assessment of Special Educational Needs (SEN) and are in receipt of such provision (Wallingford and Prout, 2000). However, evidence from relatively small selected samples of schoolchildren indicates that summer-born children with learning difficulties do not perform less well on age-standardised tests (IQ, mathematical ability, reading ability, communication skill) than their older classmates (Bibby et al., 1996) and have been shown to perform as well as their autumn-born peers on tests of cognitive ability prior to age standardisation (Wilson, 2000). It is particularly concerning that the poorer attainment of summer-born children is not confined to the primary classroom but persists into secondary and tertiary education. At GCSE summer-born children attain 2–3 per cent Does season of birth matter?

Longer-term psychiatric adjustment of children and parents after meningococcal disease.

Objective: To ascertain whether increases in psychological symptoms in children and parents after meningococcal disease are sustained over time, and to examine the psychosocial and illness associations of 12-mo psychological outcome. Design: A prospective, cohort study using repeated measures. Setting: Three pediatric intensive care units and 19 general pediatric wards across greater London. Patients: Fifty-six children, aged 3 to 16 yrs, admitted to hospital with meningococcal disease and their parents. Measures and Main Results: Child and parent psychological symptoms were measured, using the Strengths and Difficulties Questionnaire (SDQ) and the General Health Questionnaire (GHQ) at three time points: before/during hospital admission, 3 mos, and 12 mos after discharge. The Impact of Event Scale (IES) was used at the two follow-up points. During the follow-up period, there were statistically significant increases over child pre-illness levels in parent-rated emotional, conduct, hyperactivity, and impact SDQ scores; the most significant change at 12-mo follow-up was an increase in impact on daily living scores. At 12 mos, five (11%) of 43 children were at risk for posttraumatic stress disorder. The strongest correlations of 12-mo child psychological symptoms (total SDQ scores)—in addition to premorbid total SDQ score—were illness-related changes in parenting, maternal IES and GHQ scores. At 12 mos, 13 (24%) of 54 mothers and six (15%) of 40 fathers scored at high risk for posttraumatic stress disorder. The strongest correlation of maternal posttraumatic stress disorder symptoms (IES scores) was paternal posttraumatic stress disorder symptoms. Conclusions: Admission to the hospital with meningococcal disease is followed by an increase in psychological symptoms in children at home, some of which are persistent and impairing, and by continuing posttraumatic stress symptoms in a proportion of children and parents. Psychosocial (pre- and postmorbid) factors predict problems at 12-mo follow-up.

Testing the Feasibility of Therapeutic Identification of Depression in Young People in British General Practice

PURPOSE Depression in young people attending primary care is common and is associated with impairment and recurrence into adulthood. However, it remains under-recognized. This study evaluated the feasibility of training primary care practitioners (PCPs) in screening and therapeutic identification of adolescent depression, and assessed its effects on practitioner knowledge, attitudes, screening, and management. METHODS We trained PCPs in therapeutic identification of adolescent depression during general practice consultations. To assess changes in knowledge and attitudes, PCPs completed questionnaires before and after training. We ascertained changes in depression screening and identification rates in the 16 weeks before and after training from electronic medical records of young people aged 13-17 years. Post-training management of depression was recorded on a checklist. RESULTS Aspects of practitioner knowledge (of depression prevalence and treatment guidelines) and confidence (regarding depression identification and management) increased significantly (all p < .04). Overall screening rates were enhanced from .7% to 20% after the intervention and depression identification rates from .5% before training to 2% thereafter (29-fold and fourfold increases, respectively). Identification was significantly associated with PCP knowledge of prior mental health problems (Fishers exact test, p = .026; odds ratio, 4.884 [95% confidence interval, 1.171-20.52]) and of psychosocial stressors (Fishers exact test, p = .001; odds ratio, 17.45 [95% confidence interval, 2.055-148.2]). CONCLUSIONS The Therapeutic Identification of Depression in Young People program is a feasible approach to improving primary care screening for adolescent depression, with promising evidence of effectiveness. Further evaluation in a randomized trial is required to test practitioner accuracy, clinical impact, and cost benefit.

General practitioners’ understanding of depression in young people: qualitative study

Background Depression in young people is not necessarily self-limiting, and is frequently associated with affective disorders and impaired psychosocial functioning in adult life. Early recognition of and response to depression in teenagers could be an important task for general practitioners (GPs), but there are multiple obstacles to achieving this. Objectives To explore GPs perceptions of the opportunities and difficulties of working with teenagers, and of specifically recognizing and responding to depression. Setting and participants Nine GPs who had taken part in a developmental project on diagnosing and treating depression in young people. All worked in an Inner London Medical Centre. Methods Semi-structured interviews transcribed and analysed thematically. Findings Two over-arching themes that emerged from the interviews were that teenagers were perceived as being qualitatively different from adults in the ways they used general practice, and that GPs were uncomfortable with making a diagnosis of depression in young people. Within the first theme, we identified sub-themes, including failure of teenagers to engage with services, parental involvement, complex presentations and lack of time. Within the second theme, the sub-themes were surprise, normalization of depressed mood and challenge to the validity of psychiatric diagnosis in this age group. Conclusions Professional development in general practice that addresses this topic needs to modify two perceptions; that depressed mood is in some sense ‘normal’ in this age group, and that teenagers are so different in their use of services that the management of depression (if it is recognized at all) is problematic.

First trimester ultrasound screening : Carries ethical and psychological implications

Letters p 748 Ultrasound scanning has been an integral part of antenatal care in industrialised countries for some time,1 but until recently detection of fetal abnormalities by this method has been possible only in the second trimester. High resolution scanning during the first trimester is now possible and is routine in some units. Not only chromosomal abnormalities but also structural anomalies can be diagnosed by this means,2 and the advent of such a capability raises both ethical and psychological issues. While healthcare professionals in maternity services are good at giving some sorts of information to patients—for example, on nutrition during pregnancy—they may fail to consider the issues of informed consent raised by the use of such a powerful diagnostic tool during routine antenatal care. 3 4 Most women being offered these scans are at low risk of fetal abnormality and the scan constitutes their first visual encounter with their baby. They may believe that it will provide information only about gestational age and be unaware of the range of abnormalities that can be detected. Recent research suggests that many women are not told beforehand of …

Treading a fine line: is diagnosing depression in young people just medicalising moodiness?

Depressed mood in young people is common, with a prevalence of up to 20% among teenagers consulting their GP.1 Depression during the teenage years is associated with functional impairment and health risk behaviours;2,3 episodes can be severe and prolonged, often not resolving over 18 months.4 Adolescent depression is a chronic and relapsing condition with a high level of continuity into adulthood,5,6 where it is associated with impaired psychosocial functioning.2 Even young people with low levels of depressive symptoms and associated impairment — so-called ‘subsyndromal depression’ — have been shown to have persistent impairment.7 There is some evidence that intervention can reduce psychological morbidity and it is therefore possible that early intervention could alter the experience of mental ill-health in later life.8 However, young people with psychological morbidity are difficult to engage in psychological therapies,9 even though such therapies appear to reduce symptoms and case prevalence.10 This reluctance to engage reduces the capacity of GPs and their practice counsellors to review depressed teenagers. The NICE guidelines on depression in children and young people11 argue for enhanced detection and risk profiling in community settings, but the precise means to achieve this remain unclear. GPs may be seen as being well placed to undertake detection and …