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R. Lynn, D. Nicholls, R. Viner. Institute of Child Health, London, UK
BackgroundRare disease and infections are by definition individually uncommon, but collectively are an important cause of morbidity and mortality in childhood. For 20 years the British Paediatric Surveillance Unit (BPSU) has been successful in addressing this via the collection of national data on rare childhood conditions. Many such conditions affect a child's mental wellbeing but their epidemiology cannot be investigated without the input of child and adolescent psychiatrists.
Aims(1) To evaluate a system set up to undertake surveillance of early onset eating disorders (EOED); (2) to undertake an evaluation of the clinicians views on such a system; (3) identify potential areas for future study.
MethodFor a period of 15 months from March 2005 a yellow card, modelled on the BPSU orange card, was sent monthly to child and adolescent psychiatrists identified through the Royal College of Psychiatrists. The card asked participants to report EOEDs for children aged 5–12 years inclusive, seen in the previous month. Study details including the case definition, objectives and reporting instructions were circulated along with a monthly newsletter. Paediatricians also reported EOEDs through the BPSU orange card. Non‐respondents were re‐contacted after 3 months. Following a reported case, a proforma was sent to the respondent seeking descriptive data on the case. After 15 months of surveillance an evaluation questionnaire was sent out to those who were eligible to receive a report card.
ResultsThe average monthly response rate for the yellow card was 84%. 379 (75%) of 505 reports were via the card, of which 321 were confirmed, 234 (73%) by psychiatrists. The overall questionnaire response rate was 87%, 81% by psychiatrists. 95% of psychiatrists were willing to contribute to a monthly card‐reporting scheme; 20% would prefer to report electronically. Psychiatrists identified problems with remembering cases and accessing records for problems in returning data. Conditions identified for future study include, Tourette's syndrome, conversion disorder, PANDAS and bipolar disorders.
ConclusionsThe data collected using a monthly report card were reliable and valid. This suggests that a child psychiatric surveillance system to compliment the BPSU could be a useful tool in providing information on the mental health of children.
D. Nicholls1, R. Lynn2, R. Viner3. 1Great Ormond Street and the Insitute of Child Health, London, UK; 2RCPCH Research Unit, London, UK; 3UCLH and the Institute of Child Health, London, UK
BackgroundThe ambiguous position of early‐onset eating disorders (EOED: onset <age 13) between paediatric and mental health services, together with difficulties of recognition in this age group, has led to gaps in knowledge about prevalence, presentation and management. This paper describes the range of clinical features at presentation of cases presenting to secondary care.
MethodsPaediatricians and child psychiatrists were asked to report cases meeting the case definition over one year, through the BPSU and a newly created surveillance system for Child and Adolescent Psychiatrists in the NHS and private sector. Duplicate reporting was encouraged. Clinical information was sought from reporting clinicians by questionnaire.
ResultsIn 206 confirmed cases, mean age was 11.5 years (SD 1.3); mean duration of symptoms prior to diagnosis was 8.2 months; sex ratio F:M 4.7:1. 76 (37%) met operational criteria for anorexia nervosa (AN); 4 (2%) for bulimia nervosa (BN), 83 (41%) for eating disorder not otherwise specified (EDNOS) and 38 (18%) for other eating problem. This gives a total estimated incidence of 3.28/100000 children aged 5–12. 36% showed some sign of medical compromise as a result of weight loss/food avoidance (58% of those with AN). 50% were admitted to hospital (70% of those with AN), the majority to paediatric wards, for an average of 40 days. 21 patients (10%) were fed via NG tube. Binge eating (n=11), laxative abuse (n=3) and self‐induced vomiting (n=40) were rarer than excessive exercise (n=93), fear of weight gain (n=196) and weight (n=137) or shape (n=106) concerns. Somatic complaints were common in those with and without weight and shape concerns. 59% were prepubertal, 28% in early/mid puberty, and 8% late/adult.
ConclusionsSymptom and diagnostic profiles in EOED differ from adolescent and adult samples. Cases of BN and compensatory behaviours were rare. Both paediatric and psychiatric services were frequently involved in patient care. Services for children with eating disorders should reflect the differing clinical profile and developmental needs of this patient group from their adolescent counterparts.
H. Miller, A. Curran, R. McCarter, D. Pauldhas, B. Hameed, P. Sharples. Frenchay Hospital, Bristol, UK
IntroductionTBI is a major cause of childhood hospital admission, yet relatively few data exist concerning its impact on the family.
Aims(1) To measure depressive symptoms in the main carers of traumatic brain injury (TBI) children 1, 6 and 12 months after injury; (2) to compare the results with those found in carers of non‐injured controls; (3) to define the determinants of depression.
MethodsProspective cohort study. TBI was classed as severe (Glasgow Coma Score 3–8), moderate (GCS 9–12) and mild (GCS 13–15). The Beck Depression Inventory‐II (BDI) was used to measure symptoms of depression in the main carer. Cognitive outcome in the child was assessed by WISC‐III, Test of Everyday Attention in Children and Children's Memory Scale; behavioural/emotional outcome by Child Behaviour Checklist, Vineland Maladaptive Scale, Birleson Depression Scale and Impact of Events Scale; and health related quality of life by Pediatric Quality of Life Inventory. Family burden was assessed by Family Burden of Injury Inventory, family functioning by Family Assessment Device, and parental coping by Coping Inventory for Parents. Socioeconomic status was assessed by the Income Deprivation Affecting Children Index (IDACI) of the Index of Multiple Deprivation.
ResultsNinety seven TBI children (38 severe/moderate, 59 mild, mean age 11.3 years, SD 3.9) and 29 controls (mean age 11.8 years, SD 4.0) were recruited. There was a significant difference in the level of depressive symptoms between the groups at 1 and 6 months after injury but not at 12 months (p=0.011; p=0.027; p=0.158). Depressive symptoms in TBI carers were significantly higher post‐TBI than pre‐TBI (p=0.022). BDI scores >17, suggesting major depression, were seen in 26% TBI and 8% control carers at 1 month; in 29% TBI and 4% control carers at 6 months; and in 37% TBI and 6% control carers at 12 months. Depressive symptoms at all times points post‐TBI correlated significantly with family burden; family functioning; parental coping; and the child's behavioural/emotional status; at 1 and 6 months depressive symptoms also correlated with the IDACI and cognition in the child and at 1 month with measures of physical dependency in the child and impaired social functioning.
ConclusionAdmission with TBI can be associated with significant and persistent symptoms of depression in the main carer. Helping parents of TBI children develop effective coping strategies may improve long‐term outcome.
X. Poblete, E. Clark, D. Marina, C. Becky. The North West London Hospitals NHS Trust, Middlesex, UK
BackgroundIt is well recognised that health problems can impair learning and that school challenges can lead to stress and affect children's mental and physical health. The HOPES project, a local intervention run jointly by health and education, aims to help children with their worries and challenges by encouraging their active participation in Personal, Social and Health Education (PSHE).
AimTo explore children's way of dealing with common social situations at school and the impact that these may have on them.
MethodHealth and education together designed a student questionnaire looking at 3 different case scenarios of children experiencing difficulty completing school work, bullying and break up of friendship. The children were asked in each case what was the problem and why, whose problem it was, what could be done about it, what the consequences would be and how to prevent it in future. The children completed the questionnaire anonymously at school in PSHE lesson.
ResultsA total of 213 children age 13 to 14 years who had just started high school completed the questionnaire. Looking at the child having difficulties with her work 52% saw this as a problem, because it affected her learning. However, 24% also noted that it would have an affect on her health in terms of being bullied, losing confidence, struggling or panicking. In the case of bullying and break up of a friendship the main concern of the children was its effect on health. The child being bullied may go hungry, may get hurt, and may be scared, upset or become depressed or suicidal. The children who had fallen out may get teased, feel sad or depressed over the situation. Children offered many different solutions and accessed support in different ways. Children with learning difficulties or behaviour problems were more likely to internalise the problem rather than trying to resolve it or asking for help.
ConclusionChildren when faced with common social challenges at school identify concerns they have about the possible impact on their health. The children's work has given further understanding of the way the children perceive such problems and it enables health and education to develop support mechanisms, which can be more accessible to vulnerable children.
A. Abd‐Elhamid, A. Howe, R. Reading. University of East Anglia, Norwich, UK
IntroductionIn Egypt there is a widespread view that emotional and behavioural difficulties are rare, but very few data or evidence for support this view. A study to determine the prevalence of behaviour and emotional problems among primary school children was carried out in Minia, Egypt.
MethodsThe study population consisted of 1177 school children aged 6–12 years randomly selected from 10 schools. Parents and teachers were asked to fill the Arabic version of the extended form of the Strengths and Difficulties Questionnaire.
ResultsThe overall response rate was 99%. The results showed that teachers rated the children consistently high (mean 13.0 (SD 6.2)) and parents' reports although lower than teachers were still high (mean 11.6 (SD 5.9)). When reports were combined, using the multi‐informant algorithm which takes into account the impact of the problems, 8.2% of the children were found to be probable cases for any psychiatric diagnosis. The table shows estimated prevalence rates as expressed by teachers, parents and multi‐informant reports. The estimated prevalence rate is comparable to those reported in other countries.
ConclusionThere is a pressing need to improve awareness and service provision for childhood mental health problems in Egypt.
R. Belderbos1, D. Skuse2, U. Chowdhury2. 1Institute of Child Health, London, UK; 2Child and Family Service, Dunstable, UK
AimsTo determine the prevalence of undiagnosed autistic spectrum disorder in child psychiatry patients.
MethodsTwenty six children (22 males, 4 females; aged 4–18 years) recruited from child psychiatry clinic excluding those with known autistic spectrum disorder. 22 age and sex matched controls. Interviewed with 3Di (the Developmental Dimensional and Diagnostic Interview for Autism) a semistructured autism questionnaire.
ResultsTwelve (46%) of child psychiatry scored positive for Autistic Spectrum Disorder (2 classical autism; 2 atypical autism and 8 Pervasive Developmental disorder‐Not Otherwise Specified). No controls scored positive for autistic spectrum disorder (differences statistically significant using χ2). Multiple linear regression showed that Tourette's and ADHD were significantly correlated with all 3 autism subscales. Rates of Autistic Spectrum Disorder in these groups: ADHD 69% (OR 15; CI 2–101); Tourette's 70% (OR 17; CI 2–152).
ConclusionsA significant proportion of child psychiatry patients have undiagnosed Autistic Spectrum Disorder. Children with ADHD or Tourette's have especially high rates of ASD. This contradicts the ICD 10 criteria that these conditions cannot coexist. ASD should be tested for in emotionally or behaviourally disturbed children to allow appropriate intervention.
M. Silver. Oxford University, Oxford, UK
A randomised controlled trial looked at the effect of the Emotion Trainer on able children with autism or Asperger's syndrome. Two groups of 11 children (age 12–18) at two special schools participated. Individuals in one group used the computer program for 10 half‐hour sessions and were compared to the other group who received no intervention. Data collected within the program showed a significant reduction in errors made from first to last use. Students were assessed pre and post intervention using facial expression photographs, cartoons depicting emotion‐laden situations, and non‐literal stories. Scores were not related to age or verbal ability. The experimental group made gains relative to the control group on all three measures, reaching significance on the cartoons and stories, despite the small sample size. Gains correlated significantly with the number of times the computer program was used. Results suggest strong positive effects of using the computer program. A new enhanced version of the computer program has been developed, with greater interactivity and customisable options, such as a choice of animations themes rewarding to the child, and a choice of how many questions of each type to present at each session. A further randomised control trial is underway exploring whether the program is effective in improving the social skills of children with poor early care and attachment disruption, whether results generalise to observable social skills, and whether results are maintained at follow‐up.
S. Perera, V. Nerminathan. Southend University Hospital, Westcliff on Sea, Essex, UK
Impact of a structured clinic to improve service delivery and concordance.
ObjectiveAudit of a model of service delivery that employs teleconference consultations of child and adolescent attention deficit hyperactivity disorder (ADHD) patients and their carers and/or teachers.
MethodAll newly diagnosed (March 2004–March 2006) ADHD children and their carers were offered structured teleconference consultations to answer queries; evaluate response to treatment and adverse effects during a dedicated clinic setting. The reasons for review, diagnoses, medications and outcomes were analysed. Incremental cost‐effectiveness ratio and direct costs to patients and parents were calculated.
Results103 records were audited. audit results will be presented. The incremental cost‐effectiveness ratio was −105.8 for routine follow‐up indicating significant cost effectiveness of the teleconference consultations.
Conclusion94.2% children within an ADHD service were effectively managed using a structured teleconference consultation procedure. Only 5.8% needed their follow‐up appointments rearranged. Given the long waiting lists for follow‐up appointments, school days and parent time and money lost because of the need to attend appointments, teleconsultations need to be considered a highly cost‐effective accessory to the existing healthcare arrangements.
P. Hoare1, S. Prasad2, S. Perera3, A. McClure4, R. Joji5, M. Thompson6, L. Poole7, L. Mathieson8. 1Royal Hospital for Sick Children, Edinburgh, UK; 2Cromwell Hospital, London, UK; 3Southend University Hospital, Essex, UK; 4South Tyneside District Hospital, South Shields, UK; 5Parkview Clinic, Birmingham, UK; 6Department of Clinical Psychology, Ashurst, UK; 7Department of Neuroscience Statistics Europe, Eli Lilly and Co Ltd, Basingstoke, UK; 8Department of Neurosciences, Eli Lilly and Co Ltd, Basingstoke, UK
AimsTo describe the effects of atomoxetine on self‐esteem compared with standard current therapy (SCT) in UK paediatric patients with ADHD as rated by the children themselves.
Methods201 patients with attention deficit hyperactivity disorder (ADHD) were enrolled into SUNBEAM, a multicentre, randomised, open‐label study to receive atomoxetine (n=104) or SCT (n=97) for 10 weeks. The child‐ and adolescent‐rated Harter Self‐Perception Profiles (HSPP) were used to explore children's perceptions of themselves in terms of competence, self‐adequacy, global self‐worth or self‐esteem as a person. The data were analysed using a repeated measures mixed models analysis, the primary comparison was of the least‐squares means between treatments at week 10.
ResultsEach of the six subscale scores common to both Children's and Adolescent's versions of the HSPP (children and adolescents were combined) subscales showed improvement for patients in both groups, with Social Acceptance, Scholastic Competence, Behavioural Conduct, Athletic Competence, Physical Appearance and Global Self‐Worth. There was a statistically significant difference between the groups in the Social Acceptance subscale in favour of atomoxetine at week 10 (p=0.030) but not in the five other HSPP subscales.
ConclusionIn this open‐label trial, management of ADHD (either with atomoxetine or SCT) improved child self‐perception over the 10 week period; atomoxetine treatment had a significantly superior effect to SCT on individuals' perceptions of their status among their peers and friend, as measured by the Social Acceptance Scale of the HSPP. It is important to take children's viewpoints into consideration when making treatment decisions about their chronic illness, and indeed when running clinical studies.
S. Prasad1, K. Puvanendran2, V. Harpin3, S. Jamdar4, H. Zeitlin5, C. Yemula6, A. McClure7, R. Joji8, L. Poole9, N. Savill10. 1Eli Lilly and Co Ltd, Basingstoke, UK; 2Basildon Hospital, Basildon, UK; 3Sheffield Children's Hospital NHS Trust, Sheffield, UK; 4Wigan Child and Family Mental Health Services, Wigan, UK; 5University College London, London, UK; 6Children's Services, Bedford Heights, UK; 7South Tyneside District Hospital, South Shields, UK; 8Parkview Clinic, Birmingham, UK
AimsTo assess the broader efficacy ie improvements in health‐related quality of life (HRQL) and functional outcomes of atomoxetine compared with standard current therapy (SCT) in UK paediatric patients with attention deficit hyperactivity disorder (ADHD), as rated by parents.
Methods201 patients with ADHD were enrolled into SUNBEAM, a multicentre, randomised, open‐label study, to receive atomoxetine (n=104) or SCT (n=97) for 10 weeks. Broader efficacy was assessed using the parent‐rated Child Health and Illness Profile‐Child Edition (CHIP‐CE) total (global) t‐score. To identify more specifically the areas of impairment that may benefit from treatment, the five CHIP‐CE domains (Satisfaction, Comfort, Resilience, Risk Avoidance, Achievement) and their 12 subdomains were also evaluated. The analysis was the comparison of the least‐squares means between treatments at week 10.
ResultsHRQL of children/adolescents with ADHD was extremely compromised at baseline (23.2 (12.2) atomoxetine, 23.9 (11.0), SCT, approx 2.5 SD below the norm mean values of 50) and improved considerably over the 10 weeks for both treatment arms. The CHIP‐CE total score was statistically significantly higher for patients treated with atomoxetine (38.4 (1.3) compared with SCT (30.8 (1.3) at week 10 (p<0.001). There was a statistically significant difference between the groups in favour of atomoxetine in 9 of 12 subdomains (p0.050). The results of the CHIP subdomains will be the focus of this presentation.
ConclusionIn this UK population of children and adolescents with ADHD, management of ADHD with both atomoxetine and SCT resulted in improvements; atomoxetine was superior to SCT at 10 weeks in improving multiple aspects of HRQL. It is important to assess HRQL and functional outcomes when making treatment decisions about children with chronic illness rather than just focusing specifically on core symptomatology, and indeed when assessing treatments within the context of a clinical trial.