Margaret Steele

Case Study: Anorexia Nervosa and Autistic Disorder in an Adolescent Girl

The development of anorexia nervosa in a high-functioning, early adolescent, autistic female is described. This case raises the issue of co-occurrence of childhood-onset disorders sharing the phenomena of obsessions and compulsions. The role of dysregulation of the serotonergic neurotransmitter system as a common underlying mechanism in these disorders is suggested. Psychoactive agents affecting the serotonin system and in particular the atypical neuroleptic risperidone may be of value in these disorders. There is added benefit to the combined use of biological and behavioral therapies.

Survey of Atypical Antipsychotic Prescribing by Canadian Child Psychiatrists and Developmental Pediatricians for Patients Aged Under 18 Years

Objective: To describe self-reported patterns of prescribing atypical antipsychotics (ATAs) and monitoring practices of child psychiatrists and developmental pediatricians in Canada. Method: We surveyed members of the Canadian Academy of Child and Adolescent Psychiatry and members of the Developmental Paediatrics Section of the Canadian Paediatric Society regarding the types and frequencies of ATAs they prescribed, the ages and diagnoses of patients for whom they prescribed these medications, and the types and frequencies of monitoring used. Results: Ninety-four percent of the child psychiatrists (95%CI, 90% to 97%) and 89% of the developmental pediatricians (95%CI, 75% to 96%) prescribed ATAs, most commonly risperidone (69%). Diagnoses included psychotic, mood, anxiety, externalizing, and pervasive developmental disorders. Prescribing for symptoms such as aggression, low frustration tolerance, and affect dysregulation was also common. Twelve percent of all prescriptions were for children under age 9 years. Most clinicians monitored patients, but there were wide variations in the type and frequency of tests performed. Conclusions: Despite the lack of formal indications, ATAs were prescribed by this group of clinicians for many off-label indications in youth under age 18 years, including very young children. Neither evidence-based guidelines nor a consensus on monitoring exist for this age group.

Developing a risk-model of time to first-relapse for children and adolescents with a psychotic disorder.

Individuals treated for psychotic disorders and mood disorders with psychotic features have a high likelihood of relapse across the life course. This study examines the relapse rate and its associated predictors for children and adolescents experiencing a first-episode and develops a statistical risk-model for prediction of time to first-relapse. A multiyear, retrospective cohort design was used to track youth, under the age of 18 years, who experienced a first-episode of psychosis, and were admitted to 1 of 6 inpatient hospital psychiatric units (N = 87). Participants were followed for at least 2 years (M = 3.9, SD = 1.3) using survival analysis. Approximately 60% of subjects experienced relapse requiring hospital readmission by the end of follow-up, with 33% readmitted within the first year and 44% within 2 years. Median survival time was 34 months. Cox proportional hazards regression identified 4 key risk factors for relapse: medication nonadherence, female gender, receiving clinical treatment, and a decline in social support before first admission.

Child psychiatry practice patterns in Ontario

Objectives: To examine the demographics, training, distribution, venues of practice, remuneration patterns, and professional affiliations of child psychiatrists in Ontario. Method: In July 1997, questionnaires were sent to 229 Ontario psychiatrists. A second mailing was sent to nonresponders in the fall of 1997. The overall response rate was 66.8%. Results: Compared with other research regarding the ratio of child psychiatrists to children with mental health problems, Ontario fares relatively well (1:6148). Generally, Ontario child psychiatrists report having received formalized training in the speciality. Child psychiatrists are disproportionately concentrated in Toronto and in midsize cities with medical schools compared with rural regions. Outreach services to smaller communities are provided by 30% of child psychiatrists, but it is not clear whether the services are sufficient and equitably available. Approximately 50% of current psychiatrists will be aged 65 years or older in 15 years, and it is unclear whether sufficient numbers will replace them. The profession appears to be reaching an equitable gender representation. Most child psychiatrists belong to the professional organizations that support the profession; however, they are least likely to belong to the Ontario Psychiatric Association (OPA). Conclusions: An optimal ratio of child psychiatrists per population served still needs to be determined, with special consideration given to the needs of rural communities. The small ratio of child psychiatrists to the population of children with mental health needs highlights the importance of collaborating with other medical and mental health professionals. Recruiting and retaining child psychiatrists will need to be monitored. Child psychiatrists in Ontario need a unified voice to address these issues.

Brief report: A case of autism with interstitial deletion of chromosome 13.

A case of an 18-year-old male who meets the DSM-IV criteria for autistic disorder and borderline intelligence is described. Cytogenetic evaluation revealed a karyotype of 46, XY, del(13)(q14q22). The relevance of this case to the etiology of autism is discussed.

Suicidal behaviour in children and adolescents. Part 2: treatment and prevention.

Dear Editor: Included in their excellent review of suicidal behaviour in children and adolescents, Dr Margaret Steele and Dr Tamison Doey discuss the literature on hospital-based services for suicidal adolescents. They state that “there is no empirical evidence that hospitalization or day treatment is effective in reducing rates of suicidal ideation, attempts, or completed suicide among adolescents” and reference the Gould et al review of the past 10 years published in 2003. While we cannot comment on completed suicide, in the time since the Gould et al review, our group has published a study suggesting the possibility that inpatient treatment may reduce suicidal ideation, suicidal behaviour, and nonsuicidal self-injurious behaviour.OBJECTIVE To systematically review the treatment of suicidal behaviour in children and adolescents. METHOD After discussing the principles of treatment, we review the literature regarding adequate assessment, hospital-based services and their alternatives, and follow-up. RESULTS Treatment modalities (including psychotherapy) and preventive strategies (including school-based interventions, gatekeeper and primary practitioner training, and treatment of psychiatric disorders) are considered in the light of existing evidence. CONCLUSIONS The assessment of youth at risk for suicide should include attention to well-established risk factors, but prediction of risk remains difficult. Treatment of suicidal children and adolescents should be evidence-based and may include psychotherapy and psychopharmacology. Effective methods of prevention are emerging, but more research is needed.

Bipolar Disorder in Children and Adolescents: Current Challenges

Objective: To demonstrate the diagnostic and treatment challenges in juvenile-onset bipolar disorder. Method: Three case vignettes are outlined to demonstrate different bipolar presentations in children and adolescents. Results: These case examples illustrate important issues in the diagnosis and management of juvenile-onset bipolar disorder. These issues include diagnostic confusion with atypical initial presentation and the effect of developmental factors on symptom expression. The relationship among genetic risk, early affective instability, and the stress generated by affectively ill family members is complex and circular. Comorbidity with disruptive behaviour disorders, as well as anxiety disorders, is demonstrated by the cases discussed. Comorbid disorders may affect outcome and require separate treatment intervention. There is evidence for the prophylactic antimanic effect of lithium carbonate in children and adolescents, but its specificity as an antimanic agent is still uncertain. There is less evidence, at present, for effectiveness of other mood stabilizers in this age group, although sodium valproate may prove more effective in mixed mania and rapid cycling, which are so often seen with early-onset bipolar disorder. Conclusions: While the existence of juvenile-onset bipolar disorder is no longer in dispute, several outstanding issues related to diagnosis and long-term management remain. Careful prospective research will be necessary to sort out these issues definitively.