Patients as parents and young people approaching adulthood: how should we manage the interface between mental health services for young people and adults?

PURPOSE OF REVIEW: The present review discusses critically recent research findings (published during the period 2003-2004) on the mental health needs of young people in transition (old adolescents and young adults), including those of young parents. Also, the evidence on effective interventions and service models is considered. RECENT FINDINGS: Emerging evidence indicates that young people have high rates of mental health needs (in addition to high prevalence of psychiatric disorders) that may be related to life transitions. These needs often fall between the remit of adolescent/adult and mental health/social care services, and therefore are not adequately met. With the exception of mental health interventions for early psychosis and psychosocial programmes for teenage parents, there is very limited knowledge on how best to meet the mental health needs of young people in transition. SUMMARY: It is widely recognized that young people in transition require services and interventions tailored to their characteristics, rather than a mere extension to either child/adolescent or adult services. Recent policies and research findings have led to the development of early psychosis interventions, with initial encouraging messages. Similar initiatives are required for young people with nonpsychotic disorders.     

Official records of bullying incidents among young offenders: what can they tell us and how useful are they?

The present study describes 107 incidents of bullying recorded by staff on "Bullying Incident Reports" (BIRs) at a male Young Offender Institution. The most frequently recorded type of bullying was psychological/verbal. Bullies had been placed on a governor's report prior to the BIR and found guilty on significantly more occasions than victims. Victims were significantly more likely than bullies to be seen as at risk of/actually displaying self-injurious behaviour during their incarceration. Most bullying incidents took place in cells/accommodation or in classrooms/the education block. The results are discussed with reference to how useful official records of bullying are as a method of measuring the nature/extent of bullying.     

Assessing the severity of seizures and epilepsy: which scales are valid?

A review of the literature on methods of seizure or epilepsy severity assessments resulted in tabulation of the seizure rating scales known as US Department of Veterans Affairs (VA), Chalfont-National Hospital, Liverpool, Hague, and others. Each of the scales reviewed has some advantages, but none of them appears to be adequate to assess seizure or epilepsy severity. Most of the scales use similar components of seizures to evaluate severity. However, the disadvantages of each scale outweigh its usefulness. New approaches are needed to assess seizure severity for individuals and for use as an outcome measure after intervention such as surgery or medication changes.     

Victimizing behaviour among juvenile and young offenders: how different are perpetrators?

This study examined the victimizing behaviours of incarcerated juvenile and young offenders. A total of 108 juveniles and young offenders completed questionnaires relating to victimizing behaviours and were administered the Custodial Adjustment Questionnaire (CAQ: Thornton, 1987 In Applying Psychology to Imprisonment: Theory and Practice, McGurk B.J., Thornton, D. and Williams, M. (Eds). London: HMSO, pp. 445-465) and Hostility and Direction of Hostility Questionnaire (HDHQ: Caine et al., 1967. Manual of the Hostility and Direction of Hostility Questionnaire. London: University of London press). It was found that 50.9% of all respondents reported victimizing others, with verbal assaults and threats being the most common form of such behaviours. Furthermore, staff-identified "victimizers" were significantly more likely to report victimizing behaviour than the rest of the sample. Those who had been in custody longer were more likely to report victimizing others, as were younger offenders (15-17-year olds as compared to 18-21-year olds). Victimizers were also more likely to report having previously experienced victimization themselves. On the psychometric measures, self-reported victimizers scored significantly higher on the deviance sub-scale of the CAQ, and on a number of the sub-scales of the HDHQ. These findings are discussed in terms of previous literature and their practical implications considered.     

Referring physicians' perceptions of the neuropsychological evaluation: how are we doing?

Clinical neuropsychologists often serve as consultants to physicians. However, little is known about physicians' perceptions of the neuropsychological evaluation. Therefore, the present study examined the opinions of physicians who referred patients for neuropsychological evaluation. Surveys were mailed with the neuropsychological reports to 119 physicians who referred patients to an outpatient hospital-based neuropsychology practice over a 2-year period. Results showed that physicians requesting neuropsychological evaluations most commonly sought assistance with establishing and confirming a diagnosis, and they reported a high level of satisfaction with the evaluation, including strong agreement with diagnosis and recommendations. These findings did not differ based on physician specialty or patient diagnosis.     

CHALLENGING BEHAVIOUR AND COMMUNITY SERVICES 2. Who are the people who challenge services?

This is the second in a series of articles in Mental Handicap that explore the provision of community based services for people with severe mental handicaps and challenging behaviours. It presents information arising from the work of the South East Thames Regional Health Authority's Special Development Team that begins to answer the basic question: who are the people with severe mental handicaps whose behaviour poses a major challenge to current services?     

The influence of online images on self-harm: A qualitative study of young people aged 16–24

To date, research on the role of the Internet in self-harm has focused on young people's interaction via the medium of text, with limited consideration of the effect of images. This qualitative study explores how young people understand and use online images of self-harm. Semi-structured interviews were conducted with a community sample of 21 individuals aged 16–24 living in Wales, UK, with a previous history of self-harm. Interviewees reported the role of the Internet in normalising young people's self-harm. Images rather than textual interactions are the primary reason cited for using the Internet for self-harm purposes. Images invoke a physical reaction and inspire behavioural enactment, with Tumblr, which permits the sharing of images by anonymous individuals, being the preferred platform. Viewing online images serves a vital role in many young people's self-harm, as part of ritualistic practice. Online prevention and intervention need to attend to the importance of images.     

FASD: what types of intervention and rehabilitation are useful?

Fetal alcohol spectrum disorders (FASD) occurs worldwide when children are prenatally exposed to alcohol. This paper discusses recent findings regarding the neuropsychological and behavioral effects of prenatal alcohol exposure and how it impacts the developmental and functional abilities of children with FASD. Specifically, recent research focus has concentrated on studies to elucidate a neurobehavioral phenotype for the alcohol-exposed population. As a result, the FASD field has learned what types of neurobehavioral issues occur most frequently with these children. This paper discusses how that information can be used to inform school assessment, intervention planning, and support. Strategies for functional assessment, individualized planning, structured teaching, and developments in cognitive-behavioral methods are described.     

Debate: Child and adolescent mental health services in Pakistan; Do we need in-patient mental health facilities for children and young people?

Depression and anxiety are leading causes of morbidity in children and adolescents worldwide. In Pakistan, young people are exposed to many chronic adversities including violence, social and economic inequalities, and are at greater risk of developing mental health problems. Yet there is a lack of trained human resources, in-patient child and adolescent mental healthcare facilities, and training opportunities in child and adolescent psychiatry and mental health in Pakistan. Given the poor economic condition of the country, which has been made even worse by the COVID-19 pandemic, it is very unlikely that dedicated resources will be made available in near future to develop specialist child and adolescent mental health services in Pakistan. To bridge this treatment gap, we propose a multitiered, transdiagnostic, task-shifting strategy-based model for child and adolescent mental health services in Pakistan.     

Patient and family perceptions of the neuropsychological evaluation: how are we doing?

To assess perceptions of the neuropsychological evaluation, 349 patients and 218 significant others presenting to an academic medical center neuropsychology service were surveyed over a two year period. Thirty-seven percent of the patient surveys (n = 129) and 37% of the significant other surveys (n = 80) were returned. Overall, both patients and significant others reported being satisfied with the interview, testing, and feedback sessions. Responders were generally receptive to the recommendations made, but were more inclined to have followed recommendations regarding patient safety (63.6%) than coping or support (31.8%). Some barriers to compliance with recommendations were identified.     

Pharmacogenetics of antipsychotics: useful for the clinician?

PURPOSE OF REVIEW: The concept of individualized drug therapy on the basis of pharmacogenetics has become a central focus in psychopharmacology of schizophrenia. This article reviews recent advances in this field with respect to their importance for the clinician. RECENT FINDINGS: First, there is an increasing agreement about the importance of polymorphisms in cytochrome P450 enzymes and the effects of drug-drug interactions in relation to the incidence of adverse effects. Secondly, prediction of response on the basis of variants in candidate genes is incipient and remains elusive. Thirdly, some advances have been made in understanding the pharmacogenetics of weight gain. SUMMARY: Despite much effort, only a few of the results are now ready for translation into clinical practice. Cytochrome P450 genotyping would be a big step forward towards a more individualized drug treatment based on molecular diagnostics and could improve treatment, reduce adverse effects and increase compliance of the patients. Another promising field may be that of predicting the antipsychotic-induced weight gain and it is hoped that commercially available DNA tests may be available within the next few years. Prediction of response is still hampered by many methodological and clinical problems and is not yet available to the clinician.     

Are cross-species measures of sensorimotor gating useful for the discovery of procognitive cotreatments for schizophrenia?

Prepulse inhibition of startle (PPI), a measure of sensorimotor gating used to identify antipsychotics, is reduced in schizophrenia patients and in rodents treated with dopamine agonists or glutamate antagonists. The National Institute of Mental Health (NIMH)-funded Measurement And Treatment Research to Improve Cognition in Schizophrenia (MATRICS) program has initiated a new era in the development of procognitive cotreatments in schizophrenia, independently of treating positive symptoms. Although PPI is not a cognitive process per se, such abnormalities in attention may be predictive of or lead to cognitive deficits. Since first-generation antipsychotics block PPI deficits induced by dopamine agonists, this model cannot identify cognitive enhancers for use as cotreatments with antipsychotics. PPI deficits caused by glutamate antagonists, like the exacerbation of symptoms they produce in patients, are insensitive to dopamine antagonists, but reduced by clozapine. Similarly, both PPI and cognitive deficits in schizophrenia patients are insensitive to first-generation antipsychotics, but attenuated by clozapine. Hence, treatment-induced reversals of glutamate antagonist effects on PPI may provide animal and human models to identify treatments of cognitive deficits in patients already treated with existing antipsychotics.     

Is the good-imitator-poor-talker profile syndrome-specific in Down syndrome?: evidence from standardised imitation and language measures

The emergence of the Down syndrome (DS) behavioural phenotype during early development may be of great importance for early intervention. The main goal of this study was to investigate the good-imitator-poor-talker developmental profile in DS at preschool age. Twenty children with Down syndrome (DS; mean nonverbal mental age NMA 1 y10 m) and 15 children with non-specific mental retardation (NS-MR; mean NMA 1 y11 m) participated in this study. The Preschool Imitation and Praxis Scale (PIPS) and the Dutch version of the MacArthur-Bates Communicative Development Inventories (N-CDI) were used to determine absolute and relative (contrasted to a nonverbal mental age reference) imitation and language abilities. Results revealed that there was clear evidence for a good-imitator-poor-talker profile in preschoolers with DS. However, only the advanced bodily imitation ability seems to be syndrome-specific. Clinical implications of these findings are considered.     

Postoperative treatment and prognosis of patients with resected single brain metastasis: how useful are established prognostic scores?

Objective

To evaluate postoperative prognosis and the performance of known prognostic scores in patients treated with surgical resection for single brain metastasis.

Methods

We evaluated prognostic factors and five previously published prognostic scores in a group of 74 patients with single brain metastasis treated with surgery with or without immediate whole-brain radiotherapy (WBRT).

Results

In multivariate analysis, good performance status, absence of extracranial metastases and primary tumor control were significantly associated with improved overall survival. Survival (median 10.8 months) was not significantly prolonged by immediate WBRT. Salvage treatment was necessary in 87% of patients without immediate WBRT. All five scores identified groups of patients with superior prognosis. The recursive partitioning analysis (RPA) classes, the graded prognostic assessment (GPA) score and the score developed by Rades et al. identified a poor prognosis group, but the numbers of poor prognosis patients were very small.

Conclusions

RPA and GPA appear to have the most utility in delineating exceptionally good or poor prognosis patients after resection of single brain metastasis, but this finding remains to be validated in a larger study population. Identification and validation of suitable prognostic scores hopefully will guide decision making regarding local treatment of solitary brain metastasis.     

Bayesian neural networks for classification: how useful is the evidence framework?

This paper presents an empirical assessment of the Bayesian evidence framework for neural networks using four synthetic and four real-world classification problems. We focus on three issues; model selection, automatic relevance determination (ARD) and the use of committees. Model selection using the evidence criterion is only tenable if the number of training examples exceeds the number of network weights by a factor of five or ten. With this number of available examples, however, cross-validation is a viable alternative. The ARD feature selection scheme is only useful in networks with many hidden units and for data sets containing many irrelevant variables. ARD is also useful as a hard feature selection method. Results on applying the evidence framework to the real-world data sets showed that committees of Bayesian networks achieved classification accuracies similar to the best alternative methods. Importantly, this was achievable with a minimum of human intervention.