Psychiatric services for preschoolers: an emerging need

Objective: To describe clinical presentation and service requirements for those under six years of age referred to a specialised child and adolescent psychiatry unit.

Method: This study used a retrospective review of preschoolers, six years and younger, assessed at a child, family and adolescent psychiatric unit (January 2006 to 31 December 2010). Data analysis established predominant diagnoses (prevalence percentages) and correlations and associations (diagnoses and a range of clinical variables — Fischer's exact test and chi-square test).

Results: The sample comprised 149 subjects. Males predominated (77.2%; N = 115). Mean age of presentation was 54 months (SD=12.59). Children were referred predominantly by health professionals (36.9%; N = 55) and schools (20.8%; N = 31). Attention-deficit hyperactivity disorder (ADHD) was the most common diagnosis (52.8%; N = 70), and was not over-represented amongst boys. Girls mostly presented with anxiety disorders (44.1%; 15/34) and reactive attachment disorder (RAD) (35.3%; 12/34), and boys mostly with pervasive developmental disorders (PDD) (26%; 30/115). Psychometric testing was frequent (68.5%; N = 102). Pharmacological intervention was common (46.3%; N = 69). The defaulting rate after initial assessment was high (42.1%; 48/114).

Conclusion: The study demonstrates the existence of psychiatric illness in this sample, highlighting service needs. Vulnerability of this age group and limited sub-specialist resources emphasise the need for the development of community services leading to early recognition and intervention.     

The future of CMHCs: The role of the state

The author contends that the new de-institutionalization is masking the inability of states to establish clear authority and responsibility for the mentally ill. The determination of authority and responsibility was fatally flawed by the community Mental Health Centers Act when it did not clarify the state's role. Also discussed is how the withdrawal of direct federal funds affected community mental health center services.     

Community Psychiatric Practice: Introduction

Editorial Introduction

Community Psychiatric Practice: Introduction     

Psychiatric disorders in pediatric primary care. Prevalence and risk factors

Children aged 7 to 11 years visiting their primary care pediatrician for a wide range of reasons were studied to determine the one-year prevalence of DSM-III disorders and the risk factors associated with them. Parents completing the Child Behavior Checklist about their children identified problems that placed 24.7% of 789 children in the clinical range. Detailed psychiatric interviews with 300 parents and children, using the Diagnostic Interview Schedule for Children, yielded a one-year weighted prevalence of one or more DSM-III disorders of 22.0% +/- 3.4%, combining diagnoses based on either the child or the parent interview.     

Types of patients served by various providers of outpatient care in CMHCs

Representative community mental health center (CMHC) survey data showed that psychiatrists differed from other CMHC providers of mental health services by serving the more seriously impaired patients who are admitted and readmitted to outpatient services. Psychiatrists also shared more outpatients with providers from other disciplines than providers in other disciplines shared with one another. The results are consistent with previous research on differences between disciplines and with the flight of psychiatrists from CMHCs but cast doubt on the hypothesis that psychiatrists see sicker patients than psychologists see because of differences in reimbursement between the two disciplines.     

Practice Guidelines for Parkinson's disease

'Practice Guidelines (PG) or treatment guidelines' are not infallible guidelines but tools with which to support a clinical decision, i.e. one factor when making a clinical decision. When making a clinical decision, medical practice is determined by taking into consideration PG, a patient's preferences, and a country's social and healthcare systems. Even if a PG provides a treatment method based on a high-level of evidence, the method simply represents a mean result obtained from past clinical studies, which are not always uniformly applicable to all patients. When consulting a PG, it is advisable to know in advance what group/society/organization prepared it, the purpose of its preparation, and the developmental method, including social equity, whether healthcare costs are assumed in the PG or whether the pharmaceutical industry had substantial involvement in its development. Thus, PGs need to be developed according to the actual conditions in a country or institution. As to the questions whose answers are not provided in a PG, these issues have to be defined and assessed through a literature search. This is the so-called implementation of Evidence-Based Medicine (EBM). The concepts of EBM further require the provision of better evidence. A PG is always fated to be out of date by the time it is published because new evidence is continually being published. It is therefore, always necessary to search for the most up to date evidence available.     

The Psychiatric Family Nurse Practitioner: A Collaborator in Family Practice

The potential of the psychiatric family nurse practitioner (Psych.F.N.P.) to contribute to family practice through physical care and mental health care exists in the here and now. This role is a synthesis of 2 advanced practice roles, the psychiatric clinical nurse specialist (Psych.C.N.S.) and family nurse practitioner (F.N.P.), both of which continue to have great utility independently. This synthesis is a practical application of concepts that have evolved to meet the changing patterns of health care delivery. At this time, dual certification as a Psych.C.N.S. and F.N.P. best reflects the broad practice expertise of the psychiatric family nurse practitioner. The experienced psychiatric family nurse practitioner provides direct care for both physical and psychological needs of patients in a family practice setting.