Changed sleep according to weighted blanket adherence in a 16-week sleep intervention among children with attention-deficit/hyperactivity disorder

STUDY OBJECTIVES

To examine differences in sample characteristics and longitudinal sleep outcomes according to weighted blanket adherence.

METHODS

Children with attention-deficit/hyperactivity disorder (ADHD) (n =94), mean age 9.0 (sd 2.2, range 6-14) participated in a 16-week sleep intervention with weighted blankets (WB). Children were classified as WB adherent (use of WB ≥ 4 nights/week) or non-adherent (use of WB ≤ 3 nights/week). Changes in objectively measured sleep by actigraphy, parent-reported sleep problems (Children's Sleep Habits Questionnaire (CSHQ)) and child-reported Insomnia Severity Index (ISI) were evaluated according to adherence with mixed effect models. Gender, age, and ADHD subtype were examined as potential moderators.

RESULTS

Children adherent to WBs (48/94) showed an early response in sleep outcomes and an acceptance of the WB after four weeks of use as well as a decrease in parent- (CSHQ) (-5.73, P = .000) and child-reported sleep problems (ISI) (-4.29, P = .005) after 16 weeks. The improvement in sleep was larger among WB adherent vs. non-adherent (between-group difference: CSHQ: -2.09, P = .038; ISI: -2.58, P =.007). Total sleep time was stable for children adherent to WB but decreased for non-adherent (between-group difference: +16.90, P = .019).

CONCLUSIONS

An early response in sleep and acceptance of the WB predicted later adherence to WBs. Improvements in sleep were more likely among WB adherents vs. non-adherents. Children with ADHD may thus benefit from using WBs to handle their sleep problems.

The efficacy of weighted blankets for sleep in children with attention-deficit/hyperactivity disorder-A randomized controlled crossover trial

Weighted blankets are a non-pharmacological intervention for treating sleep and anxiety problems in children with attention-deficit/hyperactivity disorder. However, research on the efficacy of weighted blankets is sparse. The aim of this randomized controlled trial with a crossover design (4 + 4 weeks) was to evaluate the efficacy of weighted blankets on sleep among children with attention-deficit/hyperactivity disorder and sleeping problems. Children diagnosed with uncomplicated Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition attention-deficit/hyperactivity disorder with verified sleep problems were randomized to start with either a weighted blanket or a lighter control blanket. Data collection was performed at weeks 0, 4 and 8 using actigraphy, questionnaires and a daily sleep diary. T-tests were used to evaluate efficacy. The study included 94 children with attention-deficit/hyperactivity disorder (mean age 9.0 [sd 2.2] years; 54 [57.4%] boys). Weighted blankets had a significant effect on total sleep time (mean diff. 7.72 min, p = 0.027, Cohen's d = 0.24), sleep efficiency (mean diff. 0.82%, p = 0.038, Cohen's d = 0.23) and wake after sleep onset (mean diff. -2.79 min, p = 0.015, Cohen's d = -0.27), but not on sleep-onset latency (p = 0.432). According to our exploratory subgroup analyses, weighted blankets may be especially beneficial for improving total sleep time in children aged 11-14 years (Cohen's d = 0.53, p = 0.009) and in children with the inattentive attention-deficit/hyperactivity disorder subtype (Cohen's d = 0.58, p = 0.016). Our results suggest that weighted blankets may improve children's sleep and could be used as an alternative to pharmacological sleep interventions.

Empowered and engaged: Group exercise for adolescent depression - perspectives from adolescents, parents and healthcare professionals

Objectives

Depression is increasing and is a leading cause of disease burden among adolescents. Available evidence-based treatments with medication or psychotherapy have modest effects. Aerobic exercise is a hopeful alternative as an augmenter or a stand-alone treatment. Qualitative studies have shown that participants in group exercise for adolescent depression experienced improved mood and a sense of achievement, commitment and empowerment. This study aimed to explore not only adolescents' but also parents' and healthcare professionals' experiences of a group exercise intervention for adolescents with depression.

Methods

Nine adolescents who had participated in a group aerobic exercise intervention for 12 weeks, eight parents and two healthcare professionals were interviewed. We used a latent qualitative content analysis with an inductive approach that resulted in nine sub-categories, three categories and an overarching theme.

Results

The experiences of a group exercise intervention for adolescents with depression were expressed in the overarching theme 'Group exercise for adolescent depression promotes empowerment and engagement in everyday life', based on three categories: exercise alleviates depressive symptoms, exercise contributes to balance in life and exercise promotes self-esteem. However, there was variation in our results, in that not all participants experienced improvements from exercising. Adolescents described more varied experiences, while parents and healthcare professionals mainly expressed positive views.

Conclusions

Our findings suggest that group exercise for adolescent depression promotes empowerment and engagement in everyday life, according to adolescents, and more clearly so according to parents and healthcare professionals.

Inverse association of anti-inflammatory prescription fills and suicide-related mortality in young adults: Evidence from a nationwide study of Swedish regions, 2006-2021

Background

This cross-sectional study examined nationwide real-world associations between anti-inflammatory agent fills and suicide-related death rates in 20-24-year-olds across the 21 Swedish regions during 2006-2021.

Methods

Nationwide Swedish registers were used to compare regional year-wise suicide-related mortality (SRM) and dispensations for anti-inflammatory agents (ATC-code: M01) in 20-24-year-olds. Dispensations for paracetamol (ATC-code: N02BE01) was applied as a control variable. Associations between regional year-wise SRM and dispensation rates were analyzed by sex-stratified zero-inflated generalized linear mixed effect models (GLMM). Dispensation rates of paracetamol and inflammatory agents were designated as independent fixed effects variables, and year and region constituted random-intercept effects.

Results

Acetic acid derivatives and related substances (M01AB) and propionic acid derivates (M01A3) accounted for ∼71% of measured dispensation fills for anti-inflammatory agents. Diclofenac fills constituted ∼98% of the former category, whereas dispensations for Ibuprofen (∼21%), Naproxen (∼62%) and Ketoprofen (∼13%) constituted the most prescribed agents in the latter category. Regional yearly dispensation rates of anti-inflammatory agents in 20-24-year-old females were inversely associated with female SRM (β = -0.095, p = 0.0393, 95% CI -0.186, -0.005) - independent of paracetamol rates, which were unassociated to SRM (p = 0.2094). Results were confirmed in validation analyses for anti-inflammatory agents (OR = 0.7232, p = 0.0354, 95% CI [OR] 0.5347, 0.9781). No association was demonstrated in males (p = 0.833).

Conclusion

Anti-inflammatory agent dispensation rates were independently associated to lower suicide-related death rates in female 20-24-year-olds. This adds to growing evidence implicating inflammatory processes in mental disorders, warranting trials focusing on the suicide preventative potential of anti-inflammatories in young adults.

Association of Bipolar Disorder Diagnosis With Suicide Mortality Rates in Adolescents in Sweden

Importance

The association of early diagnosis and management of bipolar disorder with adolescent suicide mortality (ASM) is unknown.

Objective

To assess regional associations between ASM and bipolar disorder diagnosis frequencies.

Design, Setting, and Participants

This cross-sectional study investigated the association between annual regional ASM and bipolar disorder diagnosis rates in Swedish adolescents aged 15 to 19 years in January 1, 2008, through December 31, 2021. Aggregated data without exclusions reported at the regional level encompassed 585 suicide deaths, constituting 588 unique observations (ie, 21 regions, 14 years, 2 sexes).

Exposures

Bipolar disorder diagnosis frequencies and lithium dispensation rates were designated as fixed-effects variables (interaction term in the case of males). An interaction term between psychiatric care affiliation rates and the proportion of psychiatric visits to inpatient and outpatient clinics constituted independent fixed-effects variables. Region and year comprised random intercept effect modifiers. Variables were population adjusted and corrected for heterogeneity in reporting standards.

Main Outcomes and Measures

The main outcomes were sex-stratified, regional, and annual ASM rates in adolescents aged 15 to 19 years per 100 000 inhabitants as analyzed using generalized linear mixed-effects models.

Results

Female adolescents were diagnosed with bipolar disorder almost 3 times more often than male adolescents (mean [SD], 149.0 [19.6] vs 55.3 [6.1] per 100 000 inhabitants, respectively). Median regional prevalence rates of bipolar disorder varied over the national median by a factor of 0.46 to 2.61 and 0.00 to 1.82 in females and males, respectively. Bipolar disorder diagnosis rates were inversely associated with male ASM (β = -0.00429; SE, 0.002; 95% CI, -0.0081 to -0.0004; P = .03) independent of lithium treatment and psychiatric care affiliation rates. This association was replicated by β-binomial models of a dichotomized quartile 4 ASM variable (odds ratio, 0.630; 95% CI, 0.457-0.869; P = .005), and both models were robust after adjusting for annual regional diagnosis rates of major depressive disorder and schizophrenia. No such association was observed in females.

Conclusions and Relevance

In this cross-sectional study, lower suicide death rates in adolescent males was robustly associated with regional diagnosis rates of bipolar disorder at an estimated magnitude of approximately 4.7% of the mean national suicide death rate. The associations could be due to treatment efficacy, early diagnosis and management, or other factors not accounted for.

Separation and not residency permit restores function in resignation syndrome: a retrospective cohort study

Despite poor treatment results, a family-oriented approach and the securing of residency have been deemed essential to recovery from resignation syndrome (RS). In a retrospective cohort study, we evaluated an alternative method involving environmental therapy, with patients separated from their parents, while actively abstaining from involving the asylum process in treatment. We examined medical records, social services acts, and residential care home acts from 13 individuals treated at Solsidan residential care home between 2005 and 2020. Severity and outcome were assessed with Clinical Global Impression, Severity and Improvement subscales. Thirteen participants were included and out of these nine (69%) recovered, i.e. they very much or much improved. Out of the eight that were separated, all recovered, also, one non-separated recovered. The difference in outcome between subjects separated and not was significant (p = 0.007). Moreover, out of the five which received a residency permit during treatment, one recovered whereas four did not. The difference in outcome between subjects granted residency and not was significant (p = 0.007). The data revealed three (23%) cases of simulation where parents were suspected to have instigated symptoms. Our evaluation suggests that separation from parents and abstaining from invoking residency permit could be essential components when treating RS. Relying on a family-oriented approach, and residency could even be detrimental to recovery. The examined intervention was successful also in cases of probable malingering by proxy.

Youth with severe mental illness and complex non-somatic motor abnormalities: conflicting conceptualizations and unequal treatment

Two emerging diagnostic concepts promote distinct treatments for youth with acute-onset motor abnormalities and severe concurrent psychiatric symptoms: Pediatric acute-onset neuropsychiatric syndrome (PANS) and pediatric catatonia. Both have institutional approval in parts of Europe and in the USA, meriting an unconditional comparison of supporting evidence. Here we report results of qualitative and quantitative analyses of literature and Swedish National Registry Data suggesting that (1) catatonic patients are liable to fulfilling diagnostic criteria for PANS, (2) three conservatively assessed PANS case-reports present with possible unrecognized catatonia, (3) lithium and electroconvulsive therapy usage frequencies in Swedish minors (exclusively recommended for severe mental illness) are strongly intercorrelated and unequally distributed across Swedish counties, (4) established severe mental disorders are rarely overtly considered amongst PANS-specific research and (5) best-available evidence treatments appear markedly superior for pediatric catatonia compared to PANS in both childhood and adolescence. Prioritizing treatments for pediatric catatonia in concerned subjects could markedly improve treatment outcomes.

Moderate-to-vigorous group aerobic exercise versus group leisure activities for mild-to-moderate depression in adolescents: study protocol for a multicentre randomised controlled trial

INTRODUCTION

Depression is common, increasing among adolescents and carries risk of disability, lower educational achievements, cardiovascular disease, substance abuse, self-harm and suicide. The effects of evidence-based treatments with medication or psychotherapy are modest. Aerobic exercise is a promising intervention for adolescents with depression, but available studies are hampered by methodological shortcomings. This study aims to evaluate aerobic group exercise versus an active comparator of leisure group activities in adolescents from clinical services with mild-to-moderate depression.

METHODS AND ANALYSIS

This study is a multicentre randomised controlled trial at four psychiatric clinics in Sweden. Participants (n=122) will be randomised 1:1 to group exercise delivered by exercise professionals and supported by mental health (MH) workers or leisure activities lead by the same MH workers for 1 hour three times a week for 12 weeks. Participants will be assessed at baseline, single blind after 13 weeks and 26 weeks and openly after 1 year. Participants randomised to the leisure group will be offered exercise in the open phase. The primary outcome is clinician-rated Children's Depression Rating Scale-Revised. Secondary outcomes are self-rated Quick Inventory of Depressive Symptomatology, self-rated functioning; clinician-rated improvement and functioning; objectively measured aerobic capacity, muscular strength, muscular endurance, body composition and presence or activity of selected biological markers of neuroprotection and neuroinflammation in blood samples. Further outcomes are cost-effectiveness and adolescents', parents' and coaches' experiences of the interventions and an exploration of how the adolescents' health and lifestyle are influenced by the interventions through qualitative interviews.

ETHICS AND DISSEMINATION

The study is approved by the Swedish Ethical Review Authority (Ref. 2021-05307-01). Informed consent in writing will be provided from patients and parents of participants below 15 years of age. The results of this study will be communicated to the included participants and healthcare providers and also submitted for publication in peer-reviewed journals.

TRIAL REGISTRATION NUMBER

NCT05076214.

SLEEP: intervention with weighted blankets for children with attention deficit hyperactivity disorder (ADHD) and sleep problems: study protocol for a randomised control trial

INTRODUCTION AND OBJECTIVES

Children with attention deficit hyperactivity disorder (ADHD) have an increased risk of sleep problems. Weighted blankets are one possible non-pharmacological intervention for these problems in this group of children. However, the effectiveness of weighted blankets is insufficiently investigated. This study aims to investigate the effectiveness of weighted blankets in terms of sleep, health-related outcomes and cost-effectiveness as well as to explore children's and parents' experiences of a sleep intervention with weighted blankets.

METHODS AND ANALYSIS

This study is a randomised placebo-controlled crossover trial comparing the effect of weighted fibre blankets (active) with fibre blankets without weight (control). Children aged 6-13 years, recently diagnosed with uncomplicated ADHD with verified sleep problems, were included in the study. The study period is 4 weeks for each condition, respectively, and then an 8-week follow-up. A total of 100 children diagnosed with ADHD and sleep problems will enter the study. The primary outcomes are sleep and cost per quality-adjusted life years. The secondary outcomes are health-related quality of life, ADHD symptoms, psychological distress and anxiety. Interviews with a subsample of the participating children and parents will be conducted for exploring the experiences of the intervention.

ETHICS AND DISSEMINATION

Ethical approval of the trial has been obtained from the Swedish Ethical Review Authority (number 2019--2158) and conforms to the principles outlined in the Declaration of Helsinki (WMA, 2013). Results will be reported as presentations at peer-review conferences, in articles in peer-review journals and meetings with healthcare providers.

TRIAL REGISTRATION NUMBER

NCT04180189.

Parents' Experiences of Weighted Blankets' Impact on Children with Attention-Deficit/Hyperactivity Disorder (ADHD) and Sleep Problems-A Qualitative Study

Sleep disturbances are common among children with attention-deficit/hyperactivity disorder (ADHD). While pharmacological treatment has increased dramatically, parents often prefer non-pharmacological interventions. Research on experiences of weighted blankets and their effect in sleep improvement is scarce. The aim of this study was to explore parents' experiences of weighted blankets for children with ADHD and sleep problems, and the impact on their children's sleep. The explorative design was based on qualitative content analysis. Interviews were conducted with a purposeful sample of 24 parents of children with ADHD and sleep problems, after completing a sleep intervention with weighted blankets for 16 weeks. Parents reported that children sleeping with weighted blankets: (1) achieved satisfactory sleep, including improved sleep onset latency, sleep continuity, and sleep routines; (2) achieved overall well-being, including improved relaxation and reduced anxiety; and (3) mastered everyday life, including improved balance in life, family function, and participation in school and leisure activities. This study brings forward novel aspects of the effects of improved sleep among children with ADHD. The findings contribute to the understanding of potential positive effects of an intervention with weighted blankets critical for clinical practice to improve sleep, well-being, and everyday life of children with ADHD and their families.

Joy of living through exercise - a qualitative study of clinically referred adolescents' experiences of moderate to vigorous exercise as treatment for depression

AIM

Depression is common and rising in adolescents. Recent meta-analyses indicate a moderate effect of exercise on depression symptoms. Clinically referred adolescents and their experiences of an exercise intervention have rarely been studied. The aim of this study was to describe clinically referred adolescents' experience of moderate to vigorous exercise as a treatment for depression.

METHODS

A total of 16 clinically referred adolescents with persistent major depression, who had taken part in a 14-week aerobic exercise intervention of moderate to vigorous intensity, were interviewed. Data was analysed by latent qualitative content analysis.

RESULTS

After taking part in the exercise intervention the adolescents expressed enhanced participation in daily life and joy of living by demonstrating commitment and a sense of empowerment. The categories contained both improved vitality and structure of everyday life as well as improved self-esteem and self-control. Participation in the exercise intervention changed their self-image, relationships, school performance, and family life. The adolescents highlighted that exercising in a group was beneficial, giving security and structure.

CONCLUSIONS

Adolescents with persistent depression experienced several beneficial aspects of participating in an aerobic group exercise of moderate to vigorous intensity.

Aerobic exercise for adolescent outpatients with persistent major depression: Feasibility and acceptability of moderate to vigorous group exercise in a clinically referred sample

AIMS

To assess feasibility and acceptability of exercise in clinically referred adolescents with major depression.

METHODS

Outpatients12 to 17 years with mild to moderate persistent depression participated in a supervised, pulse monitored, 14-week aerobic exercise but without control group. Primary outcome was adherence and secondary was clinician-rated Quick Inventory of Depressive Symptomatology - Adolescent (QIDS-A₁₇-C), aerobic capacity, functioning, and well-being.

RESULTS

Twenty-one (66%) of 32 eligible adolescents with major depression with disease duration 2.4 (1.1-5.3) years and comorbid ADHD (71%) and anxiety disorders (62%) consented. Estimated maximum heart rate above 70% was achieved for mean 31.6 minutes, indicating that the intensity and duration of the exercise intervention was well received. Fourteen patients (67%) participated throughout the program and attended a median of 29 (81%, range 20-35) supporting satisfaction with the intervention by most patients. QIDS-A₁₇-C score decreased compared to baseline at 15 weeks (p < .001) and further at 1 year (p < .001). Aerobic capacity improved during the intervention but was not maintained, while functioning improved and after 1 year also well-being.

CONCLUSION

This 14 week moderate to vigorous aerobic exercise intervention was feasible and well accepted by most adolescents with persistent depression and extensive comorbidities.

Diagnostic efficiency and validity of the DSM-oriented Child Behavior Checklist and Youth Self-Report scales in a clinical sample of Swedish youth

The Child Behavior Checklist (CBCL) and Youth Self-Report (YSR) are widely used measures of psychiatric symptoms and lately also adapted to the DSM. The incremental validity of adding the scales to each other has not been studied. We validated the DSM subscales for affective, anxiety, attention deficit/hyperactivity (ADHD), oppositional defiant (ODD), conduct problems (CD), and obsessive-compulsive disorder (OCD) in consecutively referred child and adolescent psychiatric outpatients (n = 267) against LEAD DSM-IV diagnoses based on the K-SADS-PL and subsequent clinical work-up. Receiver operating characteristic analyses showed that the diagnostic efficiency for most scales were moderate with an area under the curve (AUC) between 0.70 and 0.90 except for CBCL CD, which had high accuracy (AUC>0.90) in line with previous studies showing the acceptable utility of the CBCL DSM scales and the YSR affective, anxiety, and CD scales, while YSR ODD and OCD had low accuracy (AUC<0.70). The findings mostly reveal incremental validity (using logistic regression analyses) for adding the adolescent to the parent version (or vice versa). Youth and parent ratings contributed equally to predict depression and anxiety disorders, while parent ratings were a stronger predictor for ADHD. However, the youth ADHD rating also contributed. Adding young people as informants for ODD and OCD or adding the parent for CD did not improve accuracy. The findings for depression, anxiety disorders, and ADHD support using more than one informant when conducting screening in a clinical context.

Validity of the Brief Child and Family Phone Interview by comparison with Longitudinal Expert All Data diagnoses in outpatients

Background:

The Brief Child and Family Phone Interview (BCFPI) is a standardized intake and follow-up interview used in child and adolescent mental health services (CAMHS). Although it has shown good validity compared with other measures using parent reports, it has not yet been compared with diagnoses derived from a Longitudinal Expert All Data (LEAD) procedure, which includes information from separate diagnostic interviews with parent(s) and child. The aim was to compare the BCFPI evaluation in an outpatient child and adolescent psychiatry setting with an evaluation derived from a LEAD procedure.

Methods:

At four Swedish outpatient CAMHS, 267 patients were interviewed at intake with the BCFPI. Within six weeks, patients and parents were interviewed separately with the 2009 version of the semi-structured Kiddie Schedule for Affective Disorders and Schizophrenia for School-age Children, Present and Lifetime Version (K-SADS-PL) and parents completed the Child Behavior Checklist (CBCL). LEAD diagnoses were subsequently determined by two senior clinicians based on 1.2 years of clinical records including the K-SADS-PL and ensuing information from further assessments, psychological tests, information from teachers and other informants as well as treatment outcome. The Diagnostic and Statistical Manual of Mental Disorders subscales from the CBCL and the subscales from the BCFPI were compared with LEAD diagnoses. These measured symptoms of attention-deficit hyperactivity disorder, oppositional defiant disorder, conduct disorder, separation anxiety disorder, generalized anxiety disorder, and major depressive disorder.

Results:

The criterion validity for BCFPI versus LEAD diagnoses was fair for oppositional defiant disorder (area under curve, 0.73), generalized anxiety disorder (0.73) and major depressive disorder (0.78), good for attention-deficit hyperactivity disorder (0.81) and conduct disorder (0.83), and excellent for separation anxiety disorder (0.90). The screening properties of BCFPI and CBCL were similar.

Conclusion:

The BCFPI is a concise and valid tool, performed along with the larger and more established CBCL, in screening for major psychiatric disorders. It is well suited as an intake interview in CAMHS.

Confirmatory factor analysis of the Evidence-Based Practice Attitude Scale (EBPAS) in a large and representative Swedish sample: is the use of the total scale and subscale scores justified?

Background

There is a call for valid and reliable instruments to evaluate implementation of evidence-based practices (EBP). The 15-item Evidence-Based Practice Attitude Scale (EBPAS) measures attitude toward EBP, incorporating four lower-order factor subscales (Appeal, Requirements, Openness, and Divergence) and a Total scale (General Attitudes). It is one of a few measures of EBP attitudes evaluated for its psychometric properties. The reliability of the Total scale has been repeatedly supported, but also the multidimensionality of the inventory. However, whether all of the items contribute to the EBPAS Total beyond their subscales has yet to be demonstrated. In addition, the Divergence subscale has been questioned because of its low correlation with the other subscales and low inter-item correlations. The EBPAS is widely used to tailor and evaluate implementation efforts, but a Swedish version has not yet been validated. This study aimed to contribute to the development and cross-validation of the EBPAS by examining the factor structure of t a Swedish-language version in a large sample of mental health professionals.

Methods

The EBPAS was translated into Swedish and completed by 570 mental health professionals working in child and adolescent psychiatry settings spread across Sweden. The factor structure was examined using first-order, second-order and bifactor confirmatory factor analytic (CFA) models.

Results

Results suggested adequate fit for all CFA models. The EBPAS Total was strongly supported in the Swedish version. Support for the hierarchical second-order model was also strong, while the bifactor model gave mixed support for the subscales. The Openness and Requirements subscales came out best, while there were problems with both the Appeal (e.g. not different from the General Attitudes factor) and the Divergence subscales (e.g. low reliability).

Conclusions

Overall, the psychometric properties were on par with the English version and the total score appears to be a valid measure of general attitudes towards EBP. This is the first study supporting this General Attitudes factor based on a bifactor model. Although comparatively better supported in this Swedish sample, we conclude that the use of the EBPAS subscale scores may result in misleading conclusions. Practical implications and future directions are discussed.

Screening efficiency of the Mood and Feelings Questionnaire (MFQ) and Short Mood and Feelings Questionnaire (SMFQ) in Swedish help seeking outpatients

BACKGROUND

To evaluate screening efficiency and suggest cut-offs for parent and child Mood and Feelings Questionnaire (MFQ) and the short version (SMFQ) in unselected help seeking child- and adolescent psychiatric outpatients for subgroups of 6-12 versus 13-17 year olds and boys versus girls.

METHOD

Eligible for inclusion were newly admitted outpatients age 6-17 years (n = 5908) in four Swedish child- and adolescent psychiatry clinics. They were prompted consecutively and n = 307 accepted a specific day for assessment until time slots randomly were filled. We prospectively validated the MFQ (33 items) and SMFQ (13 items) in patients (n = 186) using receiver operating characteristics against a reference test of Longitudinal Expert All Data DSM-IV depression based on a Kiddie-Schedule for Affective Disorders and Schizophrenia and 1.2 (sd .6) years of follow-up.

RESULTS

A depressive disorder was confirmed in 59 (31.7%) patients ranging from 14.0% for girls 6-12 years to 53.3% for girls 13-17 years. SMFQ performed roughly equivalent to MFQ. Adolescent score on SMFQ discriminated fairly for boys with Area Under Curve .77 (95% confidence interval .59-.81) and good (.82, .69-.91) for girls and parent ratings for adolescent girls (.85, .73-.93), but not for boys. Depression in children below age 13 could not be discriminated by MFQ or SMFQ whether filled in by child and mostly also when filled in by parent. Favouring maximum kappa value, the optimal cut-off was for MFQ self-report girls ≥32 versus boys ≥11 and for SMFQ self-report girls ≥17 versus boys ≥ 6. Suggested clinical SMFQ cut-offs for girls were ≥12 and for boys ≥ 6.

CONCLUSIONS

MFQ and SMFQ can, with gender-based cut-offs, be used for screening in clinical populations of adolescents but not in children. Parent MFQ and SMFQ can be used for adolescent girls but not boys. SMFQ is sufficient for screening.

Evaluation of a new model for assessment and treatment of uncomplicated ADHD - effect, patient satisfaction and costs

Aim: Attention-deficit/hyperactivity disorder (ADHD) is the most common diagnosis within child- and adolescent psychiatry. Waiting lists and delayed care are major issues. The aim was to evaluate if standardized care (SC) for assessment and treatment of uncomplicated ADHD would reduce resource utilization and increase satisfaction with preserved improvement within the first year of treatment.Method: Patients 6-12 years with positive screen for uncomplicated ADHD at the brief child and family phone interview (BCFPI), a routine clinical procedure, were triaged to SC. The control group consisted of patients diagnosed with ADHD in 2014 and treated as usual. BCFPI factors at baseline and follow-up after one year and resource utilization were compared.Results: Patients improved in ADHD symptoms (Cohen's d = 0.78, p < 0.001), child function (Cohen's d = 0.80, p < 0.001) and in family situation (Cohen's d = 0.61, p < 0.001) without group differences. Parents of SC patients participated more often in psychoeducational groups (75.5 vs. 49.5%, p < 0.001). SC had shorter time to ADHD diagnosis (8.4 vs. 15.6 weeks, p = 0.01) and to medication (24.6 vs. 32.1 weeks, p = 0.003). SC families were more satisfied with the waiting time (p = 0.01), otherwise there were no differences in satisfaction between the groups. Families of SC patients had fewer visits (4.7 vs. 10.8, p < 0.001) but used the same number of phone calls (6.3 vs. 6.2, p = 0.71). Costs were 55% lower.Conclusions: A SC for ADHD can markedly reduce costs with preserved quality. As resources are limited, child psychiatry would benefit from standardization.

[Dropout from Specialty Training is determined by the perception of autonomy and treatment efficacy]

The Swedish Association for Child and Adolescent Psychiatry conducted a survey among their specialty trainees in 2018. Of the 48% response rate, around 48% admitted hesitancy to continue in their chosen specialty. A further 12% planned to depart from their field after completion of training. Factors associated with discontinuation in training were the perception of ineffective psychotherapeutic treatments and a lack of autonomy at work; which was strongly correlated to the doctor's role and team collaboration. Workload was generally perceived as excessive, with not enough time for after work recovery and the subsequent negative impact on private life. However, these factors were not found to significantly affect trainees' decision to leave. The doctor's role requires better clarification and medical leadership needs to be improved, so that evidence based treatments can be offered.

The Validity of the Screen for Child Anxiety Related Emotional Disorders Revised (SCARED-R) Scale and Sub-Scales in Swedish Youth

We evaluated the clinical utility of the Swedish SCARED-R in child- and adolescent psychiatric outpatients (n = 239) and validated it against Longitudinal Expert All Data (LEAD) DSM IV diagnoses based on the Children's Schedule for Affective Disorders and Schizophrenia (KSADS) and subsequent clinical work-up and treatment outcome. The SCARED-R total score and subscales had acceptable sensitivity/specificity for child and parent reports for cut-offs based on Receiver Operating Characteristics (ROC) curves, with mostly moderate area under the curve. Sensitivity ranged from 75% (parent rated social anxiety) to 79% [child rated Generalized Anxiety Disorder (GAD)]. Specificity, ranged from 60% for child-rated GAD to 88% for parent rated social anxiety. Parent-child agreement was moderate, and each informant provided unique information contributing to most diagnoses. In conclusion, the SCARED-R is useful for screening anxiety symptoms in clinical populations. However, it cannot replace interview based diagnoses, nor is it adequate to use just one informant.

Predictive validity of the K-SADS-PL 2009 version in school-aged and adolescent outpatients

BACKGROUND

The schedule for affective disorders and schizophrenia for school-age children (K-SADS) is one of the most commonly used standardized diagnostic interviews in child and adolescent psychiatry. Validity studies are scarce, and limited to concurrent validity with other measures and clinical diagnoses.

AIMS

To evaluate the K-SADS interview in an outpatient child and adolescent psychiatry (CAP) setting with a Longitudinal Expert All Data (LEAD) procedure.

METHODS

CAP residents performed a K-SADS-PL interview with the revised 2009 version containing the new PDD section on 239 clinically referred outpatients of 6-17 years old and their parent(s). A consensus LEAD diagnosis by two senior clinicians 1.2 (SD = 0.6) years later was based on clinical records including the K-SADS and subsequent information from further assessments, information from teachers and other informants, outcome of treatment, and at least three visits after the K-SADS.

RESULTS

Predictive validity for K-SADS vs LEAD diagnoses were good-to-excellent for broader categories of anxiety disorders (κ = 0.94), depressive (κ = 0.91), behavioural (κ = 0.91) and tic (κ = 0.81) disorders, good for ADHD (κ = 0.80), and good-to-moderate for autism spectrum disorders (κ = 0.62). Bipolar, psychotic, and eating disorders were too few to be analysed.

CONCLUSION

The K-SADS diagnoses elicited from an interview with the child and one from parents on one occasion have an excellent validity for most major child psychiatric disorders. ADHD can be reliably diagnosed at one visit, but clinicians need to stay alert for possible undiagnosed ADHD. Diagnosing autism with K-SADS-PL 2009 version at one visit is not advisable.

Swedish clinical guidelines--prevention and management of metabolic risk in patients with severe psychiatric disorders

Individuals with severe psychiatric disorders are more likely than the population at large to develop metabolic derangements such as overweight and diabetes. Cardiovascular disease is also more frequently seen in this group. Contributing factors may include inappropriate diet or lack of physical activity, but antipsychotic medication may also play a role. Seven Swedish specialist medical societies have collaborated in formulating a set of concise clinically applicable guidelines-reproduced here in modified form-for the prevention and management of metabolic risk in this patient group. The importance of implementation is emphasized.

Adult quality of life and associated factors in adolescent onset schizophrenia and affective psychotic disorders

BACKGROUND

Subjects in treatment for affective disorders are usually less satisfied with life compared to subjects with schizophrenia.

AIMS

The aims of this study were to compare subjective quality of life (QoL) at adult age of adolescent onset psychotic disorders and analyse associated factors.

METHOD

Fifty-three patients with adolescent onset psychotic disorders were followed up at age 25, diagnostically re-evaluated according to the DSM-IV and assessed with the Positive and Negative Symptoms Scale, the Strauss-Carpenter Scale and the Lancashire Quality of Life Profile.

RESULTS

Subjects diagnosed with schizophrenia or schizoaffective disorder (n = 27) experienced significantly lower overall QoL than subjects with psychotic mood disorders (n = 26). Overall QoL was strongly associated to depressed mood (R2 = 0.49) in the schizophrenia group and to degree of employment (R2 = 0.39) in the mood disordered group.

CONCLUSION

Depression is a major concern in the evaluation and treatment of patients with schizophrenia, while vocational support seems particularly important after an episode of psychotic mood disorder.

Suicide and suicide attempts in adolescent-onset psychotic disorders

Eighty-eight subjects with adolescent-onset psychotic disorders (mean age+/-standard deviation 15.7+/-1.5 years), mainly schizophrenia and affective disorders, were followed up 10.6+/-3.6 years later, rediagnosed (DSM-IV) and assessed with the Positive and Negative Symptom Scale, abuse of drugs including nicotine, the Lancashire Quality of Life Profile and occurrence of suicide or suicide attempts. Four males (4.5% of subjects) had died from suicide while another 25% of the subjects had attempted suicide. Suicide attempts were associated to more depressive symptoms but fewer negative symptoms at first episode, and to number of admissions and to dependence on nicotine at follow-up in a logistic regression. Satisfaction with religion, health, family relations and safety at follow-up were inversely associated to attempting suicide but only satisfaction with religious belief remained after controlling for concurrent symptoms of anxiety and depression.

Diagnostic stability in adolescent onset psychotic disorders

The purpose was to examine the long-term stability of a diagnosis of psychotic disorder in adolescence and to focus on diagnostic change over time. A total of 88 patients with a first episode of early onset psychosis (before 19 years) were followed up an average of 10.5 years (range 5.1-18.2) after admission. This report includes the 68 patients who could be traced and interviewed with the Positive and Negative Symptom Scale and lifetime Structured Clinical Interview for DSM-IV diagnosis. An initial diagnostic split between schizophrenia spectrum and affective disorder had a good (> 80 %) Positive Predictive Validity and Sensitivity. The main diagnostic shift was an influx to schizophrenia spectrum disorder (n = 6). These patients resembled the stable affective group (n = 27) in premorbid and prodromal aspects but changed over time to resemble the poor outcome of the stable schizophrenia spectrum group (n = 28) albeit with fewer negative symptoms and a better social function. Family history of nonaffective psychosis in first or second degree relatives was often found in the "change to schizophrenia group". A diagnosis in adolescence of schizophrenia spectrum or affective psychotic disorder is usually stable over time. A subgroup of non-schizophrenia patients go on to develop a schizophrenia spectrum disorder.

[Difficulties in the treatment of psychosis in young patients with epilepsy]

Diagnostic considerations and treatment strategies in adolescents with partial complex epilepsy and emerging psychosis are discussed. We will argue for considering clozapine early in treatment if other antipsychotics have failed based on two cases; these patients both developed epilepsy in early childhood and schizophrenia in mid adolescence. Their partial complex epilepsy were unsuccessfully treated with different antiepileptic drugs. Clozapine was tried with a distinct improvement in psychotic symptoms and functional level. In both cases there was an early unexpected improvement in seizure control on clozapine. It appears that a reduction of psychotic activity improved seizure control. Later on, there appeared to be a trade off between clozapines effect on psychotic symptoms and recurrence of seizure activity.

CONCLUSION

A schizophrenic development must be taken into consideration if psychiatric symptoms emerge in adolescents with a partial complex epileptic disorder. Clozapine treatment can be considered if other antipsychotic drugs are ineffective or cause motor side effects.