Objective: Previous studies at child and youth mental health services (CYMHS) suggest that children with ADHD have poorer outcomes compared to those with other diagnoses. This study investigates... Show moreObjective: Previous studies at child and youth mental health services (CYMHS) suggest that children with ADHD have poorer outcomes compared to those with other diagnoses. This study investigates this in more detail. Methods: Children with ADHD were compared to those with ASD and those with emotional disorders, on routinely collected outcomes at CYMHS in Australia (N = 2,513) and the Netherlands (N = 844). Results: Where the emotional disorders group reached a similar level of emotional symptoms at the end-of-treatment as the ADHD and ASD groups, the latter two groups still had higher scores on ADHD and ASD symptoms (attention and peer problems). The poorer outcomes were mainly explained by higher severity at baseline. In Australia, an ADHD and/or ASD diagnosis also independently contributed to worse outcomes. Conclusion: Those with neurodevelopmental disorders within both countries had poorer outcomes than those with emotional disorders. Services should aim to optimize treatment to ensure best possible outcomes. Show less
Background A variety of information sources are used in the best-evidence diagnostic procedure in child and adolescent mental healthcare, including evaluation by referrers and structured assessment... Show moreBackground A variety of information sources are used in the best-evidence diagnostic procedure in child and adolescent mental healthcare, including evaluation by referrers and structured assessment questionnaires for parents. However, the incremental value of these information sources is still poorly examined. Aims To quantify the added and unique predictive value of referral letters, screening, multi-informant assessment and clinicians' remote evaluations in predicting mental health disorders. Method Routine medical record data on 1259 referred children and adolescents were retrospectively extracted. Their referral letters, responses to the Strengths and Difficulties Questionnaire (SDQ), results on closed-ended questions from the Development and Well-Being Assessment (DAWBA) and its clinician-rated version were linked to classifications made after face-to-face intake in psychiatry. Following multiple imputations of missing data, logistic regression analyses were performed with the above four nodes of assessment as predictors and the five childhood disorders common in mental healthcare (anxiety, depression, autism spectrum disorders, attention-deficit hyperactivity disorder, behavioural disorders) as outcomes. Likelihood ratio tests and diagnostic odds ratios were computed. Results Each assessment tool significantly predicted the classified outcome. Successive addition of the assessment instruments improved the prediction models, with the exception of behavioural disorder prediction by the clinician-rated DAWBA. With the exception of the SDQ for depressive and behavioural disorders, all instruments showed unique predictive value. Conclusions Structured acquisition and integrated use of diverse sources of information supports evidence-based diagnosis in clinical practice. The clinical value of structured assessment at the primary-secondary care interface should now be quantified in prospective studies. Show less
Roest, S.L.; Siebelink, B.M.; Ewijk, H. van; Vermeiren, R.R.J.M.; Middeldorp, C.M.; Lans, R.M. van der 2021
Routine outcome measurement (ROM) data offer unique opportunities to study treatment outcomes in clinical practice, and can help to assess the real-world impact of mental health services for... Show moreRoutine outcome measurement (ROM) data offer unique opportunities to study treatment outcomes in clinical practice, and can help to assess the real-world impact of mental health services for children and adolescents (youth). This is illustrated by studies using naturalistic data from specialist child and adolescent mental healthcare services (CAMHS), showing the proportion of patients with reliable improvement, recovery or deterioration (Burgess et al., 2015; Wolpert et al., 2016), and revealing specific subgroups of patients with greater risk of poor outcome (Garralda et al., 2000; Lundh et al., 2013; Murphy et al., 2015; Edbrooke-Childs et al., 2017). Naturalistic data are therefore undeniably necessary in addition to data derived from randomised clinical trials, which often have limited generalisability due to strict selection criteria (Rothwell, 2005; Van Noorden et al., 2014). Show less
Although referral letters (RLs) form a nodal point in a patient's care journey, little is known about their informative value in child and adolescent mental healthcare. To determine the informative... Show moreAlthough referral letters (RLs) form a nodal point in a patient's care journey, little is known about their informative value in child and adolescent mental healthcare. To determine the informative value of RLs to child and adolescent psychiatry, we conducted a chart review in medical records of minors registered at specialized mental healthcare between January 2015 and December 2017 (The Netherlands). Symptoms indicated in RLs originating from general practice (N = 723) were coded and cross-tabulated with the best estimate clinical classifications made in psychiatry. Results revealed that over half of the minors in the sample were classified in concordance with at least one reason for referral. We found fair to excellent discriminative ability for indications made in RLs concerning the most common psychiatric classifications (95% CI AUC: 60.9-70.6 for anxiety disorders to 90.5-100.0 for eating disorders). Logistic regression analyses suggested no statistically significant effects of gender, age, severity or mental healthcare history, with the exception of age and attention deficit hyperactivity disorders (ADHD), as RLs better predicted ADHD with increasing age (OR = 1.14, 95% CI 1.03-1.27). Contextual problems, such as difficulties studying, problems with parents or being bullied were indicated frequently and associated with classifications in various disorder groups. To conclude, general practitioners' RLs showed informative value, contrary to common beliefs. Replication studies are needed to reliably incorporate RLs into the diagnostic work-up. Show less
Although referral letters (RLs) form a nodal point in a patient's care journey, little is known about their informative value in child and adolescent mental healthcare. To determine the informative... Show moreAlthough referral letters (RLs) form a nodal point in a patient's care journey, little is known about their informative value in child and adolescent mental healthcare. To determine the informative value of RLs to child and adolescent psychiatry, we conducted a chart review in medical records of minors registered at specialized mental healthcare between January 2015 and December 2017 (The Netherlands). Symptoms indicated in RLs originating from general practice (N = 723) were coded and cross-tabulated with the best estimate clinical classifications made in psychiatry. Results revealed that over half of the minors in the sample were classified in concordance with at least one reason for referral. We found fair to excellent discriminative ability for indications made in RLs concerning the most common psychiatric classifications (95% CI AUC: 60.9-70.6 for anxiety disorders to 90.5-100.0 for eating disorders). Logistic regression analyses suggested no statistically significant effects of gender, age, severity or mental healthcare history, with the exception of age and attention deficit hyperactivity disorders (ADHD), as RLs better predicted ADHD with increasing age (OR = 1.14, 95% CI 1.03-1.27). Contextual problems, such as difficulties studying, problems with parents or being bullied were indicated frequently and associated with classifications in various disorder groups. To conclude, general practitioners' RLs showed informative value, contrary to common beliefs. Replication studies are needed to reliably incorporate RLs into the diagnostic work-up. Show less
Objective:Oppositional defiant disorder (ODD) consists of irritable and oppositional behaviors, both of which are associated with different problems. However, it is unclear whether irritability and... Show moreObjective:Oppositional defiant disorder (ODD) consists of irritable and oppositional behaviors, both of which are associated with different problems. However, it is unclear whether irritability and oppositionality enable classification of clinic-referred children and adolescents into mutually exclusive groups (e.g., high in oppositionality, low in irritability), and whether this classification is clinically meaningful.Method:As part of a clinical protocol, ODD behaviors were assessed at referral through a comprehensive diagnostic interview and questionnaire. Parent- and teacher-reported ODD of 2,185 clinic-referred 5- to 18-year-olds (36.9% females) were used in latent class analysis. Resulting ODD classes were compared, concurrently at referral, and, longitudinally at the end of the diagnostic and treatment process, on various clinically relevant measures that were completed by various informants, including mental health problems, global functioning, and Diagnostic and Statistical Manual of Mental Disorders (DSM) classifications.Results:Three classes emerged with high, moderate, and low levels of both irritability and oppositionality. At referral, the high class experienced the highest levels of mental health problems and DSM classifications. Importantly, all ODD classes defined at intake were predictive of diagnostic and treatment outcomes months later. Notably, the high class had higher rates of clinician-based classifications of ODD and conduct disorder, and the lowest levels of pre- and posttreatment global functioning. Additionally, the low class exhibited higher rates of generalized anxiety disorder and fear disorders.Conclusions:Irritability and oppositionality co-occur in clinic-referred youths to such an extent that classification based on these behaviors does not add to clinical inference. Instead, findings suggest that the overall ODD severity at referral should be used as a guidance for treatment. Show less
Objective To quantify general practitioners' (GPs) sensitivity to anxiety disorders (ADs) when confronted with the range of symptoms common to children with ADs. Also, to explore GPs' conscious... Show moreObjective To quantify general practitioners' (GPs) sensitivity to anxiety disorders (ADs) when confronted with the range of symptoms common to children with ADs. Also, to explore GPs' conscious preferences and implicit tendencies for referral of children with ADs to mental healthcare.Design and setting In a cross-sectional vignette-based survey, all attendees of a Dutch continuing medical education conference for primary care physicians were presented with subtitled audio fragments of five vignettes that we constructed to mimic symptom presentation of children with ADs in general practice. We asked attendees to select per vignette the most plausible diagnoses and most adequate referral option, and for their general referral preferences when they suspect each of the most common mental health problems.Participants A sample of 229 GPs, resulting in a total of 1128 vignette evaluations.Main outcome measure GPs' selection rate of ADs in the five vignettes compared with a benchmark provided by mental health professionals (MHPs).Results Overall, recognition of ADs was less likely in GPs compared with MHPs (OR=0.26, 95% CI 0.15 to 0.46). GPs varied in their recognition of anxiety, with 44.1% not once selecting anxiety as the probable presenting problem. When asked explicitly, 63.9% of the GPs reported that they would refer a child to mental healthcare when they suspect probable ADs. By contrast, only 12.0% of the GPs who recognised anxiety in the vignettes actually selected that referral option.Conclusion A significant fraction of GPs did not notice the depicted symptoms as anxiety. Despite the widespread prevalence of ADs, GPs seem to overlook anxiety already in their early diagnostic opinion. Improving GPs' familiarity with initial symptom presentation, ADs' base-rate, relevance and impact yields potential for timely recognition. Show less
Objective To quantify general practitioners' (GPs) sensitivity to anxiety disorders (ADs) when confronted with the range of symptoms common to children with ADs. Also, to explore GPs' conscious... Show moreObjective To quantify general practitioners' (GPs) sensitivity to anxiety disorders (ADs) when confronted with the range of symptoms common to children with ADs. Also, to explore GPs' conscious preferences and implicit tendencies for referral of children with ADs to mental healthcare.Design and setting In a cross-sectional vignette-based survey, all attendees of a Dutch continuing medical education conference for primary care physicians were presented with subtitled audio fragments of five vignettes that we constructed to mimic symptom presentation of children with ADs in general practice. We asked attendees to select per vignette the most plausible diagnoses and most adequate referral option, and for their general referral preferences when they suspect each of the most common mental health problems.Participants A sample of 229 GPs, resulting in a total of 1128 vignette evaluations.Main outcome measure GPs' selection rate of ADs in the five vignettes compared with a benchmark provided by mental health professionals (MHPs).Results Overall, recognition of ADs was less likely in GPs compared with MHPs (OR=0.26, 95% CI 0.15 to 0.46). GPs varied in their recognition of anxiety, with 44.1% not once selecting anxiety as the probable presenting problem. When asked explicitly, 63.9% of the GPs reported that they would refer a child to mental healthcare when they suspect probable ADs. By contrast, only 12.0% of the GPs who recognised anxiety in the vignettes actually selected that referral option.Conclusion A significant fraction of GPs did not notice the depicted symptoms as anxiety. Despite the widespread prevalence of ADs, GPs seem to overlook anxiety already in their early diagnostic opinion. Improving GPs' familiarity with initial symptom presentation, ADs' base-rate, relevance and impact yields potential for timely recognition. Show less
