HERE
IN THIS ISSUE
S
trengthening the evidence base for diagnosing and treating mental health disorders early in life represents a major challenge in the field of child and adolescent psychiatry. This issue of the Journal presents relevant contributions to better identify and treat mental disorders affecting young individuals. One of the most controversial issues in characterizing mental health disorders in children and adolescents is the diagnosis of pediatric bipolar disorder (PBD). Although similar prevalence estimates for the disorder have been found in multiple countries when adopting standardized interviews, the use of broader diagnostic criteria in clinical practice can result in inflated diagnostic rates. James and colleagues (p. 614) analyzed hospital discharges from 2000 to 2010 to investigate the rate and time trends for PBD in the United States and England. The investigators found that discharge rates for PBD were 72.1 times higher in the United States (100.9 versus 1.4 per 100,000 population) and that even after controlling for length of stay, a 12.5-fold difference remained. Because combined estimates for other childhood diagnoses were 3.9 times higher in the United States compared with England, the discrepancy in discharge rates for PBD likely represents different diagnostic practices in these countries. The clinical presentation of PBD was investigated by Pan and colleagues (p. 625), who sought to confirm a previously proposed latent structure for parent-reported manic symptoms. In a sample of 479 Brazilian children screened from the community as having “episodes of going abnormally high,” they identified a factor analysis solution with 2 dimensions: under control (UC) and exuberant. Although the 2 groups were discriminative, the exuberant dimension captured the variability of mood symptoms in the milder range, whereas the UC items reflected more intense mood symptoms. Also, only the UC dimension was associated with comorbidity, impairment, and family history of mood disorders or suicide
attempts. These findings suggest that different intensity levels of UC and exuberance should be taken into account when assessing children for a categorical diagnosis of PBD. Advances in the treatment of psychiatric disorders are also covered in this issue of the Journal. Coghill and colleagues (p. 647) examined the efficacy of long-term treatment with lisdexamfetamine for U.S. and European children and adolescents with attention-deficit/hyperactivity disorder (ADHD). red with those receiving placebo (67.5%), with most failures occurring before the second week after randomization. The rapid re-emergence of symptoms after lisdexamfetamine withdrawal emphasizes the importance of adherence to treatment in individuals with ADHD. Calvo and colleagues (p. 688) conducted a randomized controlled trial to assess the efficacy of group intervention for adolescents with early-onset psychosis and their families. The 9-month trial included adolescent patients with early-onset psychosis and at least 1 of their parents. A psychoeducational problem-solving group intervention (n¼ 27) was compared with a nonstructured group (n ¼ 28). This pilot study suggests that a problem-solving group intervention can help adolescents with psychosis and their families to manage crises because only 15% of patients in the active group had a visit to an emergency department compared with 39% in the control group. One of the hallmark features of autism spectrum disorder (ASD) is impairment in communication, with almost a third of individuals presenting marked deficits. Kasari and colleagues (p. 635) used a sequential multiple assignment randomized trial design to assess the effect of augmentation using a speech-generating device on increasing spontaneous language in minimally verbal school-age children with ASD. Results showed an increase in communicative utterances at week 24 (effect size 0.62), with the augmentation group almost doubling the rate of utterances per minute compared with baseline levels.
JOURNAL OF THE AMERICAN ACADEMY OF C HILD & ADOLESCENT PSYCHIATRY VOLUME 53 NUMBER 6 JUNE 2014
www.jaacap.org
601
THERE
ABSTRACT THINKING Building a Healthier America s the evidence base for assessing and treating mental health disorders affecting children and adolescents increases, new challenges to decrease their burden are imposed. In particular, the implementation of strategies to identify and treat those in need still represents an unachieved goal worldwide and in the United States. A recent report from the Robert Wood Johnson Foundation Commission focuses on aspects that underlie profound differences in the health of Americans.1 Titled “Time to Act: Investing in the Health of Our Children and Communities,” the report tackles issues such as experiences in early childhood, opportunities that communities provide for people to make healthy choices, and the mission and incentives of health professionals and health care institutions. Contrary to what many people in the United States and around the globe might imagine, people living in the United States are not healthier than people who live in other countries. According to the report, the fact that the country spends more money ($2.7 trillion in 2011) on health care than any other nation in the world is likely to reflect the poor health care of individuals living in the United States. This situation is true for individuals at all income levels and particularly for those in low-resource settings. Moreover, this situation has not improved in recent decades: in regard to life expectancy estimates in 1980, the United States ranked 15th among developed countries, but by 2009, it had dropped to 27th place. Throughout the report, the commission emphasizes the need to focus on strategies to promote health. These will require the involvement of individuals, community planners and leaders, and health professionals to improve opportunities for all, especially low-income children. Three major approaches to improve health in the United States, beyond medical care, are envisioned. First, investments targeting the youngest children should be a high priority. Under this recommendation are
A
objectives such as the creation of high standards for early childhood development programs, with guaranteed access for all low-income children younger than 5 years by 2025, and investment in innovative and evaluative research to ensure that current and new interventions are based on the best available evidence. Second, integration of health into community development should be achieved through the revitalization of neighborhoods. Initiatives such as the establishment of incentives and performance measurements are encouraged, with the ultimate goal of fostering collaborative approaches to build healthier communities. Third, implementing an approach that goes beyond treating illness will mean adopting a broader vision. This includes initiatives such as adopting new health “vital signs” to assess nonmedical indicators of wellness and creating incentives for health professionals to address nonmedical factors that affect health. To achieve all these goals, health professionals must play a central role in treating illness with a comprehensive assessment of all factors that influence individuals’ overall health. By focusing on early periods of life, collaborating with professionals outside the health sector, and adopting a developmental perspective with the ultimate goal of promoting health across the lifespan, child and adolescent psychiatrists can be integral players in changing this reality. Christian Kieling,
MD, PhD
[email protected] Hospital de Clınicas de Porto Alegre Universidade Federal do Rio Grande do Sul Porto Alegre, Brazil
The author gratefully acknowledges Natalie Weder, MD, of the Child Mind Institute, for her editorial input. Disclosure: Dr. Kieling has received support from the following Brazilian governmental research funding agencies: Conselho Nacional de ~o de Desenvolvimento Cientıfico e Tecnol ogico (CNPq), Coordenac¸a ~o Aperfeic¸oamento de Pessoal de Nıvel Superior (CAPES), and Fundac¸a Pesquisa do Estado do Rio Grande do Sul (Fapergs). de Amparo a http://dx.doi.org/10.1016/j.jaac.2014.03.002
REFERENCE 1. Robert Wood Johnson Foundation Commission to Build a Healthier America. Time to act: investing in the health of our children and
JOURNAL 602
www.jaacap.org
communities. http://www.rwjf.org/content/dam/farm/reports/ reports/2014/rwjf409002. Accessed March 1, 2014. OF THE
AMERICAN ACADEMY OF C HILD & ADOLESCENT PSYCHIATRY VOLUME 53 NUMBER 6 JUNE 2014
IN THIS ISSUE
S
trengthening the evidence base for diagnosing and treating mental health disorders early in life represents a major challenge in the field of child and adolescent psychiatry. This issue of the Journal presents relevant contributions to better identify and treat mental disorders affecting young individuals. One of the most controversial issues in characterizing mental health disorders in children and adolescents is the diagnosis of pediatric bipolar disorder (PBD). Although similar prevalence estimates for the disorder have been found in multiple countries when adopting standardized interviews, the use of broader diagnostic criteria in clinical practice can result in inflated diagnostic rates. James and colleagues (p. 614) analyzed hospital discharges from 2000 to 2010 to investigate the rate and time trends for PBD in the United States and England. The investigators found that discharge rates for PBD were 72.1 times higher in the United States (100.9 versus 1.4 per 100,000 population) and that even after controlling for length of stay, a 12.5-fold difference remained. Because combined estimates for other childhood diagnoses were 3.9 times higher in the United States compared with England, the discrepancy in discharge rates for PBD likely represents different diagnostic practices in these countries. The clinical presentation of PBD was investigated by Pan and colleagues (p. 625), who sought to confirm a previously proposed latent structure for parent-reported manic symptoms. In a sample of 479 Brazilian children screened from the community as having “episodes of going abnormally high,” they identified a factor analysis solution with 2 dimensions: under control (UC) and exuberant. Although the 2 groups were discriminative, the exuberant dimension captured the variability of mood symptoms in the milder range, whereas the UC items reflected more intense mood symptoms. Also, only the UC dimension was associated with comorbidity, impairment, and family history of mood disorders or suicide
attempts. These findings suggest that different intensity levels of UC and exuberance should be taken into account when assessing children for a categorical diagnosis of PBD. Advances in the treatment of psychiatric disorders are also covered in this issue of the Journal. Coghill and colleagues (p. 647) examined the efficacy of long-term treatment with lisdexamfetamine for U.S. and European children and adolescents with attention-deficit/hyperactivity disorder (ADHD). red with those receiving placebo (67.5%), with most failures occurring before the second week after randomization. The rapid re-emergence of symptoms after lisdexamfetamine withdrawal emphasizes the importance of adherence to treatment in individuals with ADHD. Calvo and colleagues (p. 688) conducted a randomized controlled trial to assess the efficacy of group intervention for adolescents with early-onset psychosis and their families. The 9-month trial included adolescent patients with early-onset psychosis and at least 1 of their parents. A psychoeducational problem-solving group intervention (n¼ 27) was compared with a nonstructured group (n ¼ 28). This pilot study suggests that a problem-solving group intervention can help adolescents with psychosis and their families to manage crises because only 15% of patients in the active group had a visit to an emergency department compared with 39% in the control group. One of the hallmark features of autism spectrum disorder (ASD) is impairment in communication, with almost a third of individuals presenting marked deficits. Kasari and colleagues (p. 635) used a sequential multiple assignment randomized trial design to assess the effect of augmentation using a speech-generating device on increasing spontaneous language in minimally verbal school-age children with ASD. Results showed an increase in communicative utterances at week 24 (effect size 0.62), with the augmentation group almost doubling the rate of utterances per minute compared with baseline levels.
JOURNAL OF THE AMERICAN ACADEMY OF C HILD & ADOLESCENT PSYCHIATRY VOLUME 53 NUMBER 6 JUNE 2014
www.jaacap.org
601
THERE
ABSTRACT THINKING Building a Healthier America s the evidence base for assessing and treating mental health disorders affecting children and adolescents increases, new challenges to decrease their burden are imposed. In particular, the implementation of strategies to identify and treat those in need still represents an unachieved goal worldwide and in the United States. A recent report from the Robert Wood Johnson Foundation Commission focuses on aspects that underlie profound differences in the health of Americans.1 Titled “Time to Act: Investing in the Health of Our Children and Communities,” the report tackles issues such as experiences in early childhood, opportunities that communities provide for people to make healthy choices, and the mission and incentives of health professionals and health care institutions. Contrary to what many people in the United States and around the globe might imagine, people living in the United States are not healthier than people who live in other countries. According to the report, the fact that the country spends more money ($2.7 trillion in 2011) on health care than any other nation in the world is likely to reflect the poor health care of individuals living in the United States. This situation is true for individuals at all income levels and particularly for those in low-resource settings. Moreover, this situation has not improved in recent decades: in regard to life expectancy estimates in 1980, the United States ranked 15th among developed countries, but by 2009, it had dropped to 27th place. Throughout the report, the commission emphasizes the need to focus on strategies to promote health. These will require the involvement of individuals, community planners and leaders, and health professionals to improve opportunities for all, especially low-income children. Three major approaches to improve health in the United States, beyond medical care, are envisioned. First, investments targeting the youngest children should be a high priority. Under this recommendation are
A
objectives such as the creation of high standards for early childhood development programs, with guaranteed access for all low-income children younger than 5 years by 2025, and investment in innovative and evaluative research to ensure that current and new interventions are based on the best available evidence. Second, integration of health into community development should be achieved through the revitalization of neighborhoods. Initiatives such as the establishment of incentives and performance measurements are encouraged, with the ultimate goal of fostering collaborative approaches to build healthier communities. Third, implementing an approach that goes beyond treating illness will mean adopting a broader vision. This includes initiatives such as adopting new health “vital signs” to assess nonmedical indicators of wellness and creating incentives for health professionals to address nonmedical factors that affect health. To achieve all these goals, health professionals must play a central role in treating illness with a comprehensive assessment of all factors that influence individuals’ overall health. By focusing on early periods of life, collaborating with professionals outside the health sector, and adopting a developmental perspective with the ultimate goal of promoting health across the lifespan, child and adolescent psychiatrists can be integral players in changing this reality. Christian Kieling,
MD, PhD
[email protected] Hospital de Clınicas de Porto Alegre Universidade Federal do Rio Grande do Sul Porto Alegre, Brazil
The author gratefully acknowledges Natalie Weder, MD, of the Child Mind Institute, for her editorial input. Disclosure: Dr. Kieling has received support from the following Brazilian governmental research funding agencies: Conselho Nacional de ~o de Desenvolvimento Cientıfico e Tecnol ogico (CNPq), Coordenac¸a ~o Aperfeic¸oamento de Pessoal de Nıvel Superior (CAPES), and Fundac¸a Pesquisa do Estado do Rio Grande do Sul (Fapergs). de Amparo a http://dx.doi.org/10.1016/j.jaac.2014.03.002
REFERENCE 1. Robert Wood Johnson Foundation Commission to Build a Healthier America. Time to act: investing in the health of our children and
JOURNAL 602
www.jaacap.org
communities. http://www.rwjf.org/content/dam/farm/reports/ reports/2014/rwjf409002. Accessed March 1, 2014. OF THE
AMERICAN ACADEMY OF C HILD & ADOLESCENT PSYCHIATRY VOLUME 53 NUMBER 6 JUNE 2014
