The use of the ADI-R as a diagnostic tool in the differential diagnosis of children with infantile autism and children with a receptive language disorder

Children with infantile autism and children with a specific receptive language disorder often show similar behavioural problems, making the differentiation between these two diagnostic categories difficult. The purpose of this study is to evaluate the usefulness of parental information in the differential diagnosis of the two types of disorders mentioned above. Sixteen children with a receptive language disorder and 11 children with infantile autism participated in the study. All children had normal non-verbal IQs. The ADI-R (Autism Diagnostic Interview-Revised) was performed with all children. The results showed that the ADI-R items reflecting behavioural features at pre-school age (age range 4–5 years) were better suited to differentiate the groups than the items reflecting behavioural features at the time of the investigation (mean age: 9 years). The items on the dimension “Reciprocal social interaction” and “Communication and language” discriminated the groups better than the items of the dimension “Restricted interests”. According to the ICD-10 algorithm of the ADI-R one child with autism and one child with a receptive language disorder were falsely classified. These false classifications were mainly due to a distorted parental perception of the child's behaviour. The ADI-R is a useful tool in the differential diagnosis of developmental disorders. Accepted: 27 April 2001     

Autism in Northern Finland

 Resent research reports show that autistic spectrum disorders may actually be more common than previously believed. General awareness and clinical knowledge of these disorders have increased, and the criteria in the ICD-10 and the DSM-IV are also now more detailed. The diagnostic criteria and the methods of ascertainment influence the prevalence. The age specific incidence obtained in this study showed the cumulative incidence to be lowest, 6.1 per 10 000, in the oldest age group of 15- to 18-year-old children, and highest, 20.7 per 10 000, in the age group of 5–7 year-olds, when the criteria of the ICD-10 and the DSM-IV were used. In this study, almost 50% of the autistic cases had a tested IQ above 70. The degree of autism, as assessed by the Childhood Autism Rating Scale (CARS), varied from mild autistic features in 8.5% through moderate in 58.5% to severe in 33.0%. Accepted: 15 November 1999     

Evaluation of neuromotor deficits in children with autism and children with a specific speech and language disorder

Several studies have described problems in motor functions in children with autism and children with a specific speech and language disorder. The purpose of this study was to identify neuromotor deficits in these neurodevelopmentally impaired children. A standardised neurological examination was performed in 11 children with childhood autism, 11 children with an expressive language disorder, 11 children with a receptive language disorder and 11 control children. The children were matched for age and non-verbal IQ, not for gender. All children had a non-verbal IQ above 85. The neurological examination procedure allowed for a qualitative and quantitative assessment of five specific neurological subsystems: fine and gross motor functions, balance, coordination and oral motor functions. The high-functioning children with autism and the children with a specific language disorder (expressive or receptive) had more motor problems than the control children on most neurological subsystems. There were few statistically significant differences between the three groups of developmentally impaired children. The frequent co-occurrence of verbal and non-verbal, in particular neuromotor, deficits in developmentally impaired children put an additional burden on the development of these children and should be diagnosed as early as possible. Accepted: 8 May 2002 The research was funded by grant AM 63/4–2 of the Deutsche Forschungsgemeinschaft. Correspondence to Dr. M. Noterdaeme     

Adolescents hospitalised with deliberate self-harm: the significance of an intention to die

 All suicide attempters admitted to medical wards in the greater Oslo area, (n = 91) aged 13–19 years, were dichotomised on the basis of one item in the Motives for Parasuicide Questionnaire (MPQ) and one item in the Suicide Intent Scale (SIS): if the intent was to die (n = 57), or not (n = 34). The two groups were compared regarding the attempt, mental health problems, and psychosocial risk factors. The attempt of adolescents with an intent to die were more serious, rated with SIS (15.7 vs. 5.7, p < 0.001), with Risk Rescue Rating (p = 0.003) or rated medically (p < 0.05). They were clinically more often depressed (61% vs. 32%, p < 0.01), felt more hopeless (Hopelessness Scale) (10.8 vs. 8.2, p < 0.05), were less disruptive (11% vs. 32%, p < 0.05) and less often abused substances (0 vs. 12%, p < 0.05). Both groups were equally burdened with other factors. Differentiation on the basis of suicidal intent delineated two groups, both with considerable psychosocial problems. Those with suicide intent had more internalising problems including depression, while those with other intents showed more externalising behaviour. The need for help in the group with no intent to die may be underestimated. Accepted: 19 June 2000     

Comparing the German versions of the Strengths and Difficulties Questionnaire (SDQ-Deu) and the Child Behavior Checklist

 The Strengths and Difficulties Questionnaire (SDQ) is a brief behavioural screening questionnaire that can be completed in about 5 minutes by the parents and teachers of 4–16 year olds. The scores of the English version correlate well with those of the considerably longer Child Behavior Checklist (CBCL). The present study compares the German versions of the questionnaires. Both SDQ and CBCL were completed by the parents of 273 children drawn from psychiatric clinics (N = 163) and from a community sample (N = 110). The children from the community sample also filled in the SDQ self-report and the Youth Self Report (YSR). The children from the clinic sample received an ICD-10 diagnosis if applicable. Scores from the parent and self-rated SDQ and CBCL/YSR were highly correlated and equally able to distinguish between the community and clinic samples, with the SDQ showing significantly better results regarding the total scores. They were also equally able to distinguish between disorders within the clinic sample, the only significant difference being that the SDQ was better able to differentiate between children with and without hyperactivity-inattention. The study shows that like the English originals, the SDQ-Deu and the German CBCL are equally valid for most clinical and research purposes. Accepted: 22 February 2000     

Prevalence of depression and depression recognition in nursing homes

Background The aim of this study was to estimate the prevalence of depression among nursing home residents, and the extent of depression recognition among nursing home staff. Random samples totaling 319 nursing home residents, drawn from a simple random sample of six downstate New York nursing homes were evaluated psychiatrically for depression. Samples of nurse aides, nurses and social workers also assessed the same residents for the presence of depressive symptomatology. Method Psychiatrists assessed residents using the Diagnostic and Statistical Manual of Mental Disorders (DSM-III-R) criteria. Depression measures used were the Cornell Scale for Depression in Dementia, the Feeling Tone Questionnaire, the Hamilton Depression Rating and the Structured Clinical Interview for DSM-III-R Personality Disorders Scale. Nursing and social services staff assessed residents using Depression Recognition Measures. Results Based on psychiatric evaluation, the prevalence estimate for probable and/or definite major depressive disorder among testable subjects was 14.4 % (95 % CI of 10.6 %–19.3 %); 15.4 % were not able to be assessed due to their refusal, impairment of consciousness, or severe physical illness. The estimate for minor depression was 16.8 % (95 % CI of 12.6 %–21.9 %). The prevalence of significant depressive symptomatology (including the category of possible depression) was 44.2 % (95 % CI of 38.2 %–50.3 %). The corresponding estimates of any depression were 19.7 % for social workers, 29 % for nurses and 32.1 % for nurse aides. Conclusions The prevalence of depressive disorders among nursing home residents is high; depression recognition is relatively low, with only 37 %–45 % of cases diagnosed by psychiatrists recognized as depressed by staff. A structured Depression Recognition Scale increased the rates of recognition (sensitivity of staff ratings) to 47 %–55 %, demonstrating the utility of the scale in increasing awareness of symptomatology. Accepted: 2 August 2001     

Thinking life is not worth living. A population survey of Great Britain

Background“Saving lives: our healthier nation” includes a target to reduce the death rate from suicide. Thoughts of suicide and feeling life is not worth living might be the first step in a pathway that can end in completed suicide. This study aims to identify factors associated with feeling life is not worth living amongst the household population of Great Britain, and to assess the strength of these associations after taking account of an individual's level of psychiatric morbidity. Methods The 1993 OPCS National Psychiatric Morbidity Surveys of Great Britain assessed psychiatric morbidity using the Revised Clinical Interview Schedule amongst a stratified, clustered probability sample of 9830 subjects representative of the British private household population aged 16–64. Results Of the sample 0.8 % (95 % CI 0.6 %–1 %) had thoughts of suicide in the week before interview and 3.1 % (95 % CI 2.7 %–3.5 %) reported thoughts of life not worth living in the week before interview. Psychiatric morbidity was most strongly associated with such thoughts. Ethnicity, marital status and low social support were strongly associated with such thoughts after adjusting for age, sex and psychiatric morbidity. Conclusions Reducing psychiatric morbidity in the population as a whole might also decrease the frequency of suicidal thoughts. Policies which improve social support at a population level might also have a large impact on prevalence of suicidal thoughts. Accepted: 14 March 2002     

Predictors of depression at eighteen. A 7-year follow-up study in a Spanish nonclinical population

This study prospectively examined predicting factors and depressive antecedents of depression in early adulthood and determined differences by sex. 199 adolescents aged 11–12 from the general community were followed up annually for 4 years and reassessed at 18 years of age. Sociodemographic data, depressive symptomatology, anxiety level, personality dimensions, self-esteem, academic aptitude and pubertal development were reported throughout this period and tested as possible risk variables of depression. At 18, depression was diagnosed using ICD-10 criteria. Of the cases of major depression (MDD) at eighteen, 30 % had been diagnosed as MDD between 12 and 14 years of age. Of the cases of MDD at eighteen, 80 % had had depressive symptomatology between the ages of 11 and 14. Subclinical scores in the Children's Depression Inventory (CDI) were early indicators of long-term risk. Gender differences were found in the risk pattern; depressive symptoms were more significant in girls than in boys. In boys, early anxious symptomatology was a significant predictor. This study reports cross-cultural data that support a continuity of depression from adolescence to young adulthood. Accepted: 8 May 2002 Correspondence to J. Canals, M.D.     

Personality disorders in former child psychiatric patients

The present case-control study was undertaken in order to investigate the long-term outcome with respect to personality disorder (PD) symptomatology in former child psychiatric in-patients as compared to matched controls from the general population. Altogether 359 former patients and 359 controls were invited to participate in the study. Of these, 164 (46 %) former patients and 193 (54 %) controls approved participation. From these, 137 age and sex-matched pairs with a mean age of 30.7 (SD = 6.8) years were constructed. Adult PD symptomatology was assessed by means of the DSM-IV and ICD-10 Personality Questionnaire (DIP-Q). There were 52 former patients (38 %) and 15 controls (10.9 %) who fulfilled criteria for at least one DSM-IV self-reported PD. There was a significantly higher prevalence for all specific self-reported PDs in former patients compared to controls. The mean number of disorders was 1.7 (SD = 2.6) in former patients and 0.3 (SD = 0.8) in controls. Moreover, former patients fulfilled more PD criteria than controls (23 vs. 11; median numbers). The former patients had significantly lower global functioning and more psychosocial problems than the controls. These problems were related to personality pathology. The results of this study indicate that child psychiatric morbidity seems to increase the risk for adult PD symptomatology. However, the results may be biased by the low participation rate. Accepted: 11 September 2002 Correspondence to Lisa Ekselius, MD, PhD     

Is grand multiparity associated with offsprings' hospital-treated mental disorders? A 28-year follow-up of the North Finland 1966 birth cohort

Background: A child born to a grand multiparous (GMP) mother (i.e. a mother who has undergone six or more deliveries) is at increased risk of perinatal complications, but it is not known whether or not GMP status is associated with child's adulthood mental disorders. Methods: The data were obtained from the unselected, general population Northern Finland 1966 Birth Cohort (n = 11,017). The cohort members (children) were followed up prospectively to the age of 28 years. Using the National Hospital Discharge Register, a total of 89 DSM-III-R schizophrenia cases were identified, as well as 55 other psychoses, 87 personality disorders, 36 cases of alcoholism, 53 depressive disorders, and 67 anxiety and other non-psychotic disorders. The association between the mother's grand multiparity and the offspring's adult hospital-treated psychiatric morbidity was analysed using a continuation ratio model, which is a modification of logistic regression. Odds ratios were adjusted for social class, maternal antenatal depression, and wantedness of pregnancy. Results: A total of 1320 mothers (12%) were GMPs. Maternal GMP status was not associated with offspring's schizophrenia, anxiety or other non-psychotic disorders. The risk of other psychoses (OR 2.3; 95% CI 1.2–4.7), alcoholism (OR 2.0; 95% CI 0.8–4.7) and depressive disorder (OR 2.2; 95% CI 1.0–4.5) was elevated among offspring of GMP mothers. Conclusions: It is possible that the mother's GMP status and the large family size associated with this are causal factors in the development of other psychoses than schizophrenia, alcoholism and depression among adult offspring. Accepted: 20 December 1999     

Prevalence of ICD-10 mental disorders in a catchment area in the city of São Paulo,Brazil

Background The prevalence (lifetime, 12-month, 1-month) of mental disorders, their relationship with sociodemographic features, and the use of services were investigated in the population aged 18 years or older living in the catchment area of a large hospital complex in the city of São Paulo, Brazil. Methods A community survey was conducted in two boroughs of São Paulo, on 1,464 residents aged 18 years or older. The assessment of psychopathology was made by CIDI 1.1, yielding diagnoses according to ICD-10 for mood disorders, anxiety disorders, non-affective psychosis, substance use disorders, dissociative and somatoform disorders, and cognitive impairment. Results Of the total sample, 45.9 % had at least one lifetime diagnosis of mental disorder, 26.8 % in the year, and 22.2 % in the month prior to interview. The most prevalent disorders (lifetime, 12-month, and 1-month, respectively) were: nicotine dependence (25 %, 11.4 %, 9.3 %), any mood disorder (18.5 %, 7.6 %, 5 %) with depressive episode the most prevalent mood disorder (16.8 %, 7.1 %, 4.5 %), any anxiety disorder (12.5 %, 7.7 %, 6 %), somatoform disorder (6 %, 4.2 %, 3.2 %), and alcohol abuse/dependence (5.5 %, 4.5 %, 4 %). No gender differences were found in overall morbidity. Excluding substance use disorders, women had a higher risk for non-psychotic disorders. The presence of psychiatric diagnosis increased the use of services, with a low proportion of subjects seeking specialty mental care. Conclusion Our results confirm the high prevalence of mental disorders in the community, similar to findings in other countries. A comparison with findings from other studies with similar methodology is made.     

Diagnostic assessment of communicative and interactive behaviours in children with autism and receptive language disorder

 Children with autism and children with a severe specific receptive language disorder both show clear deficits in communicative language skills and in social relationships. In this study the usefulness of the Autism Diagnostic Observation Schedule (ADOS) in the differential diagnosis between these two groups of developmentally impaired children is assessed. 11 children with early infantile autism and 20 children with a specific receptive language disorder participated in the study. 18 children with an expressive language disorder were used as a control group. The ADOS was individually administered to all children by the same examiner. The results showed that on most of the ADOS measures the autistic children were clearly more deviant than the language impaired children. There were no significant differences between the two groups of language impaired children. Eight out of 11 autistic children reached the defined cut-off values on the measures “language and communication” and “social interaction” of the ADOS algorithm, whereas only three autistic children did so on the measure “stereotyped behaviour”. None of the language-impaired children reached the cut-off values on more than one measure. The ADOS allowed for good assessment of certain types of behaviour. However, to confirm the diagnosis of infantile autism, additional information from parents is required. Accepted: 15 February 2000     

Assessing the developmental level in Rett syndrome: an alternative approach?

Reviewing the literature concerning the developmental level of Rett Syndrome (RS) girls, one is confronted with important difficulties in interpreting the meaning of the results of these studies. Anecdotal evidence from parents suggests that RS girls might understand more than these studies indicate. Analyses of these examples suggests that there are other learning mechanisms than those assessed in classical developmental tests, which are important for RS girls in order to learn to know and understand their world. Studies on learning and memory in early infancy have demonstrated a variety of such mechanisms and – particularly classical conditions – provide a theoretical framework to understand the learning processes of these girls. Based on this theoretical background, an assessment strategy can be developed, with the possibility to differentiate even very low functioning RS girls. Accepted: 14 June 1999     

Psychosocial factors and adequacy of services for children in children's homes

Risk and protective factors of psychosocial development in children in different residential care settings need to be further studied internationally, in order to develop working methods for social and health care services. Standardized methods of the CBCL, TRF, and CGAS, were used to evaluate psychosocial functioning of children in children's homes in Finland. Further, data on sociodemographic situations and traumatic events in their lives were assembled. The percentage of behavioural and emotional problems within clinical or borderline range in the different ratings was 55–80%. Combined traumatization, sexual abuse, school difficulties, male sex, older age (>11 years) and older age at first and on-going placement (>7 years), as well as difficulties in relationships with parents are likely to be associated with more severe behaviour problems and lower general functioning. The results of this study show that children and adolescents in social service residential settings are a highly vulnerable group and that these children have extensive mental health needs. Accepted: 11 November 1998     

Gender and age-specific first incidence of DSM-III-R psychiatric disorders in the general population

Background Prospective studies in the general population are needed to identify risk factors for mental disorders. Samples of sufficient size are needed, but large-scale studies that assess the incidence of psychopathology are rare. Aims The aim of this study was to investigate the 12-month first incidence rates (IR) by age and gender for 15 specified DSM-III-R disorders in the general population. Methods The study was based on a representative sample (N = 5618) of the Dutch population aged 18–64. Results The IR for any disorder was 5.68 per 100 person-years at risk (men 4.45, women 6.94). IRs for both men and women were highest in the youngest age category. The most common 12-month incident disorders in men were alcohol abuse (IR = 4.09) and major depression (1.72). In women, the most common incident disorders were major depression (IR = 3.90) and simple phobia (3.17). Conclusions The results show the rarity of first-onset of mental disorders. IRs vary strongly between the different life phases, as well as between men and women. This suggests potential target areas for age-specific and gender-specific prevention. Accepted: 19 March 2002     

Excess mortality among long-stay psychiatric patients in Northern Finland

Background: According to several studies, mortality in psychiatric patients is higher than in the general population, but cause-specific mortality analyses in long-stay psychiatric patients have not been studied very much. Individual follow-ups have been called for in order to identify possible treatment deficiencies and to make recommendations for clinical practices. In this study, mortality of long-stay psychiatric patients has been monitored for the years 1992–2000 and contrasted with that prevalent in the general population. Method: Data on psychiatric patients (N = 253) who were treated without a break for at least 6 months during 1992 in the Department of Psychiatry at Oulu University Hospital were linked with the National Death Register. Standardised mortality rates (SMRs) were determined according to gender, age groups, and different causes of death. Results: Of the total study population, 80.2 % had schizophrenia, 5.1 % other functional psychoses, 9.5 % organic mental disorders, 2.4 % personality disorders and 2.8 % mood disorders. Sixty-nine (27.3 %) of the patients (aged 31–88 years) had died before the end of the year 2000. The all-cause death risk for both males and females was four times that of the general population. The mortality risk was over ten-fold for males and almost 30-fold for females in the youngest age group (25–34 years), with suicides explaining about 75 % of these deaths. SMRs were found to decrease at older age, mortality thus approaching that of the general population. Diseases of the circulatory system were the most common single cause of death in both genders and mortality due to that cause exceeding mortality in the general population nearly 3.6-fold. However, the probability of death was highest (SMR 17.5) in connection with diseases of the digestive system. Increased risks of death due to respiratory complications (SMR 9.3), accidents (SMR 5.1) and neoplasms (SMR 2.1) were also noted. The overall death rates did not differ in relation to social class or professional education. Conclusions: Long-stay psychiatric patients were found to die from the same natural causes as the rest of the general population. However, the mortality risk of the long-stay psychiatric patients compared with that of the general population was notably higher, despite ongoing improvements in medical care and facilities. Inadequately organised somatic care and the prevailing culture of “non-somatic” treatment in psychiatry were suggested to, at least in part, explain this phenomenon. Attention ought to increasingly focus on somatic examinations and various health educational programmes specially designed for psychiatric patients and involving matters like healthy diet, smoking cessation and physical exercise. These practices should be a regular part of any patient's treatment programme. Also, the need to recognise factors associated with a patient's psychiatric disorder that could limit that patient's ability to communicate somatic symptoms and/or even lead to a refusal by that patient to have somatic diseases treated was seen as essential for providers of psychiatric services. Accepted: 4 December 2002 Correspondence to Sami R?s?nen, M. D., Ph. D.     

DSM-IV Conduct Disorder symptoms in adolescents as markers of registered criminality

A nationwide sample of 1,079 Norwegian adolescent psychiatric in-patients, 581 males and 498 females, were followed up after 11–33 (mean 23.2) years. On the basis of detailed records from index hospitalisation they were re-diagnosed and retrospectively scored on 14 of the 15 behaviour items listed as diagnostic criteria for conduct disorder in DSM-IV. The patient list was linked to the national criminal registry, and 48 % were found to have a criminal record. The ability of the 14 behaviour items to identify overall and specific kinds of registered criminality was investigated. In males, “stealing” was the strongest marker for overall and violent crime. “Having forced someone into sexual activity” was a strong marker for later sex offences. In females, “running away from home” was strongly associated with overall and violent registered criminality. ROC curves were constructed to test the sensitivity and specificity of the sum of conduct disorder behaviour items fulfilled in the identification of individuals with registered criminality. The area under the curve was 0.81 (95 % c. i. = 0.78–0.85) in males and 0.75 (95 % c. i. = 0.71–0.80) in females. A cut-off at 3 criteria fulfilled seemed optimal in males and somewhat high in females. Accepted: 17 May 2001     

Language development at ten months

Aims Language development was followed from infancy to primary school age in order to examine the predictive significance for later language and scholastic outcome. Methods Participants were from a prospective longitudinal study of a birth cohort of initially 362 children. A subsample of 90 children (54 boys, 36 girls) was administered with the Receptive–Expressive Emergent Language Scale (REEL) in order to obtain age-appropriate measures of expressive and receptive language at the age of 10 months. At 11 years, children completed a comprehensive test battery assessing various intellectual skills and language performance. Scholastic measures included a school performance score and a recommendation for type of secondary school. Results Both expressive and receptive language performance at 10 months were significantly associated with cognitive and educational outcome 10 years later. Infant language performance not only predicted later verbal and nonverbal skills but also school achievement at the end of primary school. Prediction was higher in girls than in boys and slightly better for verbal and academic than for nonverbal performance. Conclusions The results demonstrate the importance of early language abilities in predicting cognitive and academic outcome at school age.     

Does socioeconomic status predict course and outcome in patients with psychosis?

Background We examined the relationship between socioeconomic status (SES) and course and outcome of patients with psychosis. Two hypotheses were examined: a) patients with higher best-ever SES will have better course and outcome than those with lower best-ever SES, and b) patients with greater downward drift in SES will have poorer course and outcome than those with less downward drift. Method Data were drawn from the baseline and 2-year follow-up assessments of the UK700 Case Management Trial of 708 patients with severe psychosis. The indicators of SES used were occupational status and educational achievement. Drift in SES was defined as change from best-ever occupation to occupation at baseline. Results For the baseline data highly significant differences were found between best-ever groups and negative symptoms (non-manual vs. unemployed – coef −10.5, p=0.000, 95 % CIs 5.1–15.8), functioning (non-manual vs. unemployed – coef −0.6, p=0.000, 95 % CIs 0.3 to −0.8) and unmet needs (manual vs. unemployed – coef 0.5, p=0.004, 95 % CIs 0.2–0.9). No significant differences between best-ever groups were found for days in hospital, symptoms, perceived quality of life and dissatisfaction with services. Significant differences for clinical and social variables were found between drift and non-drift SES groups. There were no significant findings between educational groups and clinical and social variables. Conclusions Best-ever occupation, but not educational qualifications, appeared to predict prognosis in patients with severe psychosis. Downward drift in occupational status did not result in poorer illness course and outcome. Accepted: 3 August 2001     

Delayed Language Onset as a Predictor of Clinical Symptoms in Pervasive Developmental Disorders

DSM-IV states that Asperger Disorder may be distinguished from Autistic Disorder by a lack of a delay in early language development. The aim of this study was to establish whether the presence or absence of early language delay would predict autistic symptomatology in children diagnosed with a PDD/autism spectrum disorder. Forty-six language-delayed and 62 normal language onset individuals (M age 11 years) were compared on ICD-10 research criteria and DSM-IV criteria, receptive language, and developmental history variables. Retrospective data were also obtained to determine whether language onset predicted autism symptomatology when young (<6 years). We found that early language delay predicts more autistic symptomatology when young, but not at an older age. Early language delay is also associated with developmental motor milestone delays and lower receptive language abilities. The results question the use of early language delay as a valid discriminating variable between PDD subgroups.