Search

Between 2019 and 2022, there was a marked rise in adolescents/young adults seeking urgent help for functional tic-like behaviours (FTLBs). Given the global scale of this phenomenon, we aimed to pool cases from different institutions in an international registry to better characterize this spectrum and facilitate future longitudinal observation.An international collaborative group from 10 tertiary referral centres for tic disorders collected retrospective data on FTLB patients who sought specialists' attention between the last quarter of 2019 and June 2022. An audit procedure was used for collection of data, which comprised demographics, course of presentation and duration, precipitating and predisposing factors, phenomenology, comorbidities, and pharmacological treatment outcome.During the study period, we collected data on 294 patients with FTLBs, 97% of whom were adolescents and young adults and 87% of whom were female. FTLBs were found to have a peak of severity within 1 month in 70% of patients, with spontaneous remissions in 20%, and a very high frequency of complex movements (85%) and vocalizations (81%). Less than one-fifth of patients had pre-existing primary tic disorder, 66% had comorbid anxiety disorders, 28% comorbid depressive disorders, 24% autism spectrum disorder and 23% attention deficit/hyperactivity disorder. Almost 60% explicitly reported exposure to tic-related social media content. The vast majority of pharmacologically treated patients did not report benefit with tic-suppressing medications.Our data from the largest multicentre registry of FTLBs to date confirm substantial clinical differences from primary tic disorders. Social modelling was the most relevant contributing factor during the pandemic. Future longitudinal analyses from this database may help understand treatment approaches and responsiveness.

Tuberous sclerosis complex (TSC) is a genetic disorder caused by mutations on the TSC1/TSC2 genes, which result in alterations in molecular signalling pathways involved in neurogenesis and hamartomas in the brain and other organs. TSC carries a high risk for autism spectrum disorder (ASD) and attention-deficit/hyperactivity disorder (ADHD), although the reasons for this are unclear. One proposal is that TSC-related alterations in molecular signalling during neurogenesis lead to atypical development of neural networks, which are involved in the occurrence of ASD and ADHD in TSC. We investigated this proposal in young people with TSC who have been studied longitudinally since their diagnosis in childhood. Electroencephalography (EEG) was used to examine oscillatory connectivity in functional neural networks and local and global network organisation during three tasks (resting-state, attentional and inhibitory control Go/Nogo task, upright and inverted face processing task) in participants with TSC (n = 48) compared to an age- and sex-matched group of typically developing Controls (n = 20). Compared to Controls, the TSC group showed hypoconnected neural networks in the alpha frequency during the resting-state and in the theta and alpha frequencies during the Go/Nogo task (P ≤ .008), as well as reduced local network organisation in the theta and alpha frequencies during the Go/Nogo task (F = 3.95, P = .010). There were no significant group differences in network metrics during the face processing task. Increased connectivity in the hypoconnected alpha-range resting-state network was associated with greater ASD and inattentive ADHD symptoms (rho≥.40, P ≤ .036). Reduced local network organisation in the theta-range during the Go/Nogo task was significantly associated with higher hyperactive/impulsive ADHD symptoms (rho = −.43, P = .041). These findings suggest that TSC is associated with widespread hypoconnectivity in neural networks and support the proposal that altered network function may be involved in the co-occurrence of ASD and ADHD in TSC.

Effective support for autistic individuals is lacking in Brazil. Few centres offer services and those that do are limited in therapeutic options and geographical location. Paediatric Autism Communication Therapy is a low-intensity, evidence-based parent-mediated social-communication intervention that may be useful for this scenario. This implementation study aimed to assess the acceptability and feasibility of Paediatric Autism Communication Therapy for young autistic children (aged 2–10 years) in Brazil. Parents ( n = 18) of 2- to 10-year-old autistic children and clinicians ( n = 20) who work with autistic children in Brazil were interviewed and the data analysed using thematic analysis to explore their perceptions concerning the acceptability and feasibility of Paediatric Autism Communication Therapy. In addition, Paediatric Autism Communication Therapy was delivered to a case series of 15 further parent–child dyads; these parents were interviewed at the end of the therapy, and the data were analysed using thematic analysis. All parents and clinicians had favourable opinions about the acceptability, feasibility and perceived effectiveness of a parent-mediated intervention conducted mainly in the home. However, they also highlighted obstacles concerning the implementation of Paediatric Autism Communication Therapy in Brazil, especially related to engaging Brazilian parents in a parent-mediated model of therapy. Based on these data, minor adaptations were made to the original Paediatric Autism Communication Therapy protocol to facilitate the implementation of the intervention in Brazil. Lay abstract Parents of autistic children and health professionals who work with autistic children in Brazil had positive views about introducing Paediatric Autism Communication Therapy as a therapy for autistic children in Brazil. The parents and clinicians also mentioned some difficulties about using Paediatric Autism Communication Therapy in Brazil. We made adaptations to Paediatric Autism Communication Therapy to address these difficulties. Paediatric Autism Communication Therapy is a therapy to support the development of social and communication skills for autistic children aged 2–10 years. The therapy is conducted with the autistic child’s parent. Paediatric Autism Communication Therapy has not been used in Brazil before. There are few therapy options available for autistic children in Brazil and we believed that Paediatric Autism Communication Therapy may be useful. We asked three groups of people in Brazil about their views of Paediatric Autism Communication Therapy, after explaining how the therapy works. Group 1 included 18 parents of autistic children aged 2–10 years. Group 2 included 20 health professionals such as psychologists who work with autistic children. Group 3 included 15 parents of autistic children aged 2–7 years who received the Paediatric Autism Communication Therapy. We learned that parents and clinicians felt that Paediatric Autism Communication Therapy would be a beneficial therapy for autistic children in Brazil. We also found out about the challenges of using Paediatric Autism Communication Therapy in Brazil. We used these findings to make small cultural adaptations to Paediatric Autism Communication Therapy to make it more suitable for Brazil.

Background and purpose: In 2020, health professionals witnessed a dramatic increase in referrals of young people with rapid onset of severe tic-like behaviours. We assembled a working group to develop criteria for the clinical diagnosis of functional tic-like behaviours (FTLBs) to help neurologists, pediatricians, psychiatrists, and psychologists recognize and diagnose this condition. Methods: We used a formal consensus development process, using a multiround, web-based Delphi survey. The survey was based on an in-person discussion at the European Society for the Study of Tourette Syndrome (ESSTS) meeting in Lausanne in June 2022. Members of an invited group with extensive clinical experience working with patients with Tourette syndrome and FTLBs discussed potential clinical criteria for diagnosis of FTLBs. An initial set of criteria were developed based on common clinical experiences and review of the literature on FTLBs and revised through iterative discussions, resulting in the survey items for voting. Results: In total, 24 members of the working group were invited to participate in the Delphi process. We propose that there are three major criteria and two minor criteria to support the clinical diagnosis of FTLBs. A clinically definite diagnosis of FTLBs can be confirmed by the presence of all three major criteria. A clinically probable diagnosis of FTLBs can be confirmed by the presence of two major criteria and one minor criterion. Conclusions: Distinguishing FTLBs from primary tics is important due to the distinct treatment paths required for these two conditions. A limitation of the ESSTS 2022 criteria is that they lack prospective testing of their sensitivity and specificity.

Background There is little understanding of the mental health impact for young people with long-term physical health conditions and mental health professionals’ experiences of supporting them during COVID-19. This service evaluation aimed to conduct a survey of the psychological services provided by mental health professionals in a paediatric hospital in relation to COVID-19. Method Clinical psychologists and assistant psychologists ( n = 76) across the hospital were asked to complete a survey, asking about their perceptions of COVID-19’s impact on patients and families and experiences of providing support during COVID-19. Open-ended survey questions were analysed qualitatively using framework analysis. Results Respondents described perceived impacts on patients and families around social isolation, school closure, family relationships, physical health, mental health, treatments and social support. Respondents’ experiences of providing mental health support during COVID-19 highlighted themes around providing remote/virtual support, workload and facilitators and barriers to their work. Conclusions Mental health professionals surveyed reported a complex mental health landscape in young people with long-term physical health conditions and their families during COVID-19. Service-wide involvement is needed to facilitate changes to support vital adaptations to remote/virtual working. Research on the mental health of young people with long-term physical health conditions and staff experiences of providing support is warranted.

BackgroundChildren and young people with long-term physical conditions have significantly elevated mental health needs. Transdiagnostic, brief psychological interventions have the potential to increase access to evidence-based psychological treatments for patients who attend health services primarily for physical health needs.ObjectiveA non-randomised study was conducted to assess the impact of brief, transdiagnostic psychological interventions in children and young people presenting at a drop-in mental health centre in the reception area of a paediatric hospital.Methods186 participants attending a transdiagnostic mental health drop-in centre were allocated to assessment and psychological intervention based on a clinical decision-making algorithm. Interventions included signposting, guided self-help based on a modular psychological treatment and referral to the hospital’s paediatric psychology service. The primary transdiagnostic mental health outcome measure was the parent-reported Strengths and Difficulties Questionnaire (SDQ), which was given at baseline and 6 months post-baseline.FindingsThere was a significant positive impact of attending the drop-in mental health centre on the SDQ (Cohen’s d=0.22) and on the secondary outcome measure of Paediatric Quality of life (Cohen’s d=0.55).ConclusionsA mental health drop-in centre offering brief, transdiagnostic assessment and treatment may reduce emotional and behavioural symptoms and improve quality of life in children and young people with mental health needs in the context of long-term physical conditions. A randomised controlled trial to investigate the specificity of any effects is warranted.Clinical implicationsDrop-in centres for mental health needs may increase access and have beneficial effects for children and young people with physical conditions.

To examine the association between perinatal adversities and neurodevelopmental outcome in tuberous sclerosis complex (TSC).The Tuberous Sclerosis 2000 study is a prospective, longitudinal UK study of TSC. In phase 1, mutation type, TSC family history, tuber characteristics, presence of cardiac rhabdomyomas, seizure characteristics, and intellectual ability were assessed in 125 children affected with TSC (64 females, 61 males; median age 39mo, range 4-254). In phase 2, 88 participants (49 females, 39 males; median age 148mo, range 93-323) were assessed for neurodevelopmental outcomes including intellectual ability, autism spectrum disorder, and attention-deficit/hyperactivity disorder. Perinatal histories of 88 participants with TSC and 80 unaffected siblings were collected retrospectively using the Obstetric Enquiry Schedule and coded with a modified Gillberg Optimality Scale to measure levels of perinatal adversity. Data were analysed using Mann-Whitney U tests, Spearman's rank correlation, and linear regression with robust standard errors.Children with familial TSC experienced significantly greater perinatal adversity than unaffected siblings. Perinatal adversity was higher in children with TSC-affected mothers than those with unaffected mothers. There was no significant association between perinatal adversities and neurodevelopmental outcomes after controlling for confounders.Maternal TSC is a significant marker of elevated perinatal risk in addition to risks incurred by fetal genotype. Pregnancies complicated by maternal or fetal TSC require higher vigilance, and mechanisms underlying increased perinatal adversity require further research.Higher perinatal adversity is associated with familial tuberous sclerosis complex (TSC). Maternal TSC was associated with higher frequencies of several perinatal risk markers. Paternal TSC was not associated with higher levels of perinatal adversity. Perinatal adversity levels in TSC1 and TSC2 subgroups did not differ significantly. Perinatal adversities were not associated with neurodevelopmental outcomes.

Children with genetic conditions may experience significant mental health difficulties such as anxiety and challenging behaviour. However, understanding of the feasibility and effectiveness of psychological interventions for emotional and behavioural problems in the context of genetic conditions is limited. Low-intensity psychological interventions have demonstrated promise in paediatric populations and may be able to address their mental health difficulties. A case series design was used to assess the feasibility of low-intensity interventions for emotional and behavioural difficulties in children and young people with genetic conditions recruited from a mental health drop-in centre at a tertiary hospital. Participants received seven weekly sessions with a trained practitioner. The intervention was based on existing modular treatments and evidence-based self-help materials. Feasibility and treatment satisfaction were assessed, as well as measures of symptoms of anxiety and challenging behaviour, treatment goals and quality of life, at baseline, during treatment and 6-month follow-up. Five participants received treatment for challenging behaviour, one for anxiety, and one for obsessive compulsive disorder. All participants completed treatment. Clinically significant change in the SDQ Total score was found in three participants. All participants demonstrated progress in goals and symptoms of emotional and behavioural difficulties over the course of treatment. Low-intensity psychological interventions for emotional and behavioural difficulties in children and young people with genetic conditions is feasible, acceptable and potentially beneficial. Further research is warranted to examine the effectiveness of the intervention and its use in clinical paediatric settings. Key learning aims (1) To gain a basic understanding of low-intensity psychological intervention in children and young people with genetic conditions. (2) To enhance understanding of the practicalities and acceptability of delivering low-intensity psychological intervention to children and young people with genetic conditions and co-morbid emotional and behavioural difficulties. (3) To learn about the potential clinical benefits of delivering low-intensity psychological intervention to children and young people with genetic conditions in the context of stepped care.

Background Children with chronic health conditions and their parents are at greater risk of developing emotional and behavioural problems compared to their physically healthy peers. The psychological impact on parents is crucial to understand given the relationship between parental mental health and child emotional and behavioural difficulties. This study was part of a broader research project examining the acceptability, feasibility and impact of a ‘Mental Health and Psychological Wellbeing Drop‐in Centre’ in a paediatric hospital providing access to support and intervention for children and their families. This paper aimed to investigate the impact of the centre on parents (n = 148). Methods Parental anxiety and depression were assessed using the GAD‐7 and PHQ‐9 at baseline and 6‐month post‐baseline. Child mental health was assessed using the parent‐report Strengths and Difficulties Questionnaire (SDQ). If parents had significant mental health needs, a brief intervention/signposting to relevant services was provided. Results At baseline, 48% of parents scored above clinical threshold for anxiety and 41% for depression, and parent reported child SDQ scores were correlated with parental anxiety and parental low mood. Self‐reported parental anxiety and low mood decreased at 6‐months post‐baseline (parental anxiety: mean decrease = 2.29 [1.22–3.36], d = 0.38; parental low mood: mean decrease = 1.81 [0.64–3.00], d = 0.28). There were no significant correlations between change in parent reported child wellbeing and changes in parental low mood and anxiety between baseline and 6‐month post‐baseline. Conclusions Assessing and providing a brief treatment to address the mental health needs of parents of children with comorbidity may bring important benefits. It is recommended that children's mental health services consider assessment of parental mental health as part of routine care.

Background and aimClinical centres have seen an increase in tic-like movements during the COVID-19 pandemic. A series of children and adolescents are described.MethodsA retrospective chart review of 34 consecutive paediatric patients presenting with sudden onset tic-like movements, seen over 6 months.Results94% of patients were female, with an average age of sudden onset or increase of tic-like movements of 13.7 years. 44% had a previous diagnosis of tics, and 47% initially presented to an emergency department. Comorbid psychiatric and neurodevelopmental disorders were reported in 91% with 68% reporting anxiety.ConclusionWe highlight a dramatic presentation of sudden onset functional tic-like movements in predominantly female adolescents to help inform identification and management. There is need to research the neurobiological underpinnings and environmental exacerbating factors leading to these presentations and to explore effective therapeutic strategies.

Background Paediatric patients being treated for long-term physical health conditions (LTCs) have elevated mental health needs. However, mental health services in the community are difficult to access in the usual course of care for these patients. The Lucy Project – a self-referral drop-in access point—was a program to address this gap by enrolling patients for low-intensity psychological interventions during their treatment for LTCs. In this paper, we evaluate the cost-effectiveness of the Lucy Project. Methods Using a pre-post design, we evaluate the cost-effectiveness of the intervention by calculating the base-case incremental cost-effectiveness ratio (ICER) using outcomes data and expenses recorded by project staff. The target population was paediatric patients enrolled in the program with an average age of 9 years, treated over a time horizon of 6 months. Outcome data were collected via the Paediatric Quality of Life Inventory, which was converted to health utility scores using an instrument found in the literature. The QALYs were estimated using these health utility scores and the length of the intervention. We calculate a second, practical-case incremental cost-effectiveness ratio using streamlined costing figures with maximum capacity patient enrolment within a one-year time horizon, and capturing lessons learned post-trial. Results The base-case model showed an ICER of £21,220/Quality Adjusted Life Years (QALY) gained, while the practical model showed an ICER of £4,359/QALY gained. The practical model suggests the intervention garners significant gains in quality of life at an average cost of £309 per patient. Sensitivity analyses reveal use of staff time was the greatest determinant of the ICER, and the intervention is cost-effective 75% of the time in the base-case model, and 94% of the time in the practical-case model at a cost-effectiveness threshold of £20,000/QALY gained. Conclusions We find the base-case intervention improves patient outcomes and can be considered cost-effective according to the National Institute for Health and Care Excellence (NICE) threshold of £20,000—£30,000/QALY gained, and the practical-case intervention is roughly four times as cost-effective as the base-case. We recommend future studies incorporate a control group to corroborate the effect size of the intervention.

Background: Tuberous Sclerosis Complex (TSC) is a single gene disorder carrying high risk of autism spectrum disorder (ASD). Various neurological complications increase the risk of ASD but the way risk factors operate together is unclear. We aimed to explore risk pathways to ASD by modelling the interplay between genetic mutation (TSC1/TSC2), cortical tuber count, seizure type and severity. Methods: The Tuberous Sclerosis 2000 Study is a UK longitudinal study of the natural history of TSC. We recruited newly diagnosed children (N=125) and collected data on mutation, cortical tuber count (cranial MRI/CT), seizure history, and IQ. ASD and IQ assessments were carried out at 10-year follow up (N=86, M age=13.1 years). Structural equation modelling (SEM) was used to explore pathways that mediate between mutation and ASD symptoms. Results: Risk of ASD was high: 39.5% met research criteria for ASD and a further 41.9% showed autistic traits. SEM resulted in two indirect pathways, with cortical tuber count and occurrence/severity of epileptic spasms in infancy mediating between mutation and ASD (mutation-tubers-spasms-ASD, B=2.08, 95%CI 0.15–8.02; mutation-spasms-ASD, B=2.98, 95%CI 0.04–8.89). Concurrent seizures (B=3.08, 95%CI 0.42–6.18) and IQ (B=-117.10, 95%CI -183.57–-59.16) were also associated with ASD symptoms. Conclusions: There was significantly elevated risk of ASD and subclinical autistic traits. Tuber count and severity of spasms predicted ASD severity, suggesting that prevention/control of seizures in infancy may decrease severity of ASD symptoms. ASD was occasionally reported in the absence of overt seizures in infancy, so their causal role requires further investigation.

To evaluate neuropsychiatric comorbidities in children and adolescents with hypothalamic hamartoma.We retrospectively analysed case notes for all individuals with hypothalamic hamartoma referred to Great Ormond Street Hospital, London, between 2000 and 2016. In addition, a systematic review aiming to identify all previous paediatric case series was performed. Psychiatric symptoms, demographics, physical comorbidities, and cognitive functioning were recorded for all cases where possible. Analyses were performed to determine which factors were associated with psychopathology and potential mechanisms investigated.Forty-six cases were included in the case series (28 males, 18 females; mean age at assessment 11y 8mo [1y 11mo-16y 11mo, SD 4y 0mo]). Twenty-nine papers representing data from 264 cases met inclusion criteria for the systematic review. Overall, at least 50% of cases presented with psychopathology. Epilepsy, intellectual disability, and male sex were associated with externalizing disorders (attention-deficit/hyperactivity disorder, conduct and oppositional defiance disorders, and rage attacks). Intellectual disability mediated the effects of epilepsy on externalizing psychopathology. No factors were associated with internalizing disorders (anxiety and depressive disorders), although these were not well reported.Psychiatric comorbidities are highly prevalent in the presentation of paediatric hypothalamic hamartoma. The aetiology of psychopathology comprises a range of interacting biological and psychosocial factors with particular influence from epilepsy. Further research is required to achieve an evidence base for treatment.Over half of children with hypothalamic hamartoma present with psychiatric comorbidity. Externalizing and internalizing disorders are present in approximately 60% and 30% of children with hypothalamic hamartomas respectively. Epilepsy and male sex are associated with externalizing psychopathology. Intellectual disability mediates the association between epilepsy and externalizing symptoms. No clear associations are evident for internalizing disorders or precocious puberty.PERFIL NEUROPSIQUIÁTRICO DEL HAMARTOMA HIPOTALÁMICO EN PEDIATRÍA: REVISIÓN SISTEMÁTICA Y SERIE DE CASOS: OBJETIVO: Evaluar las comorbilidades neuropsiquiátricas en niños y adolescentes con hamartoma hipotalámico. MÉTODO: En este estudio analizamos retrospectivamente las notas de los casos de todos los individuos con hamartoma hipotalámicos referidos al Great Ormond Street Hospital, London, entre el 2000 y 2016. Además, realizamos una revisión bibliográfica sistemática dirigida a identificar la serie de casos pediátricos. Síntomas psiquiátricos, demográfico, comorbilidades físicas y funcionamiento cognitivo fueron recolectados en todos los casos posibles.Se efectuaron análisis para determinar qué factores se asociaron con psicopatología y se investigaron mecanismos potenciales. RESULTADOS: En total 46 casos fueron incluidos en la serie de casos (28 masculinos, 18 femeninos, media de edad a la evaluación 11 años y 8 meses, DS 4 años y 0 mes). La revisión bibliográfica identifico 29 artículos describiendo 264 casos que reunieron criterios de inclusión para la extracción de datos. En total, al menos 50% de casos presentaban psicopatología. Epilepsia, discapacidad intelectual, y sexo masculino fueron asociados con desórdenes externos (déficit de atención con hiperactividad, desórdenes conductuales y oposicional desafiante, ataques de furia). Ningún factor fue asociado con la internalización de desórdenes neuropsiquiátricos (desórdenes de ansiedad y depresión), aunque éstos no fueron bien reportados. INTERPRETACIÓN: Las comorbilidades psiquiátricas son altamente prevalentes en la presentación del hamartoma hipotalámico pediátrico. La etiología de la psicopatología comprende un rango de interacciones biológicas y factores psicosociales con particular influencia de la epilepsia. Se requiere más información de investigación para reunir evidencia científica que guie el tratamiento.PERFIL NEUROPSIQUIÁTRICO DO HAMARTOMA HIPOTALÂMICO PEDIÁTRICO: REVISÃO SISTEMÁTICA E SÉRIE DE CASOS: OBJETIVO: Avaliar comorbidades neuropsiquiátricas em crianças e adolescentes com hamartoma hipotalâmico. MÉTODO: Nós analisamos retrospectivamente os registros de casos de todos os indivíduos encaminhados para o Hospital Great Ormond Street, Londres, entre 2000 e 2016. Além disso, uma revisão sistemática visando identificar todos os casos pediátricos prévios foi realizada. Sintomas psiquiátricos, dados demográficos, comorbidades físicas, e funcionamento cognitivo foram registrados para todos os casos em que foi possível. Análises foram realizadas para determinar quais fatores se associavam com psicopatologia e potenciais mecanismos foram investigados. RESULTADOS: Quarenta e seis casos foram incluídos na série de casos (28 do sexo masculino, 18 do sexo feminino; média de idade na avaliação 11a 8m (1a 11m-16a 11m, DP 4a 0m). Vinte e nove artigos representando dados de 264 casos atenderam aos critérios de inclusão para a revisão sistemática. No total, pelo menos 50% dos casos apresentaram psicopatologia. Epilepsia, deficiência intelectual, e sexo masculino eram associados com desordens externalizantes (transtorno de déficit de atenção e hiperatividade, transtornos de conduta e de desafio oposicional, e ataques de raiva). A deficiência intelectual mediou os efeitos da epilepsia e da psicopatologia externalizante. Nenhum fator foi associado com transtornos internalizantes (ansiedade e transtornos depressivos), embora estes não tenham sido bem reportados. INTERPRETAÇÃO: Comorbidades psiquiátricas são altamente prevalentes na apresentação do hamartoma hipotalâmico pediátrico. A etiologia da psicopatologia envolve uma variedade de fatores biológicos e psicossociais que interagem, com particular influência da epilepsia. Mais pesquisas são necessárias para se atingir uma base de evidências para o tratamento.

Background Children and young people with long term physical health conditions (LTC) are known to have higher levels of co-morbid mental health problems than medically healthy children. Evidence-based treatments for mental health problems are effective in children who also have an LTC. A drop-in centre in a paediatric hospital, delivering a range of interventions including onward referral, signposting and guided self-help, may be one way to complement existing mental health services as part of a stepped-care approach. The aim of this study was to understand patients’ perspectives of the centre. Methods 128 patients attending a drop-in centre at Great Ormond Street Hospital were invited to participate. Overall, 35 participated in semi-structured interviews (either in person or by phone) exploring their experience of the drop-in centre. Interviews were audio-recorded, transcribed, and analysed using Framework analysis. Results Overall, participants found the drop-in centre highly acceptable and reported a positive experience. Reasons for this varied, but broadly focused around four areas:(1) Choice in how to access the intervention and feeling empowered afterwards; (2) Having someone to talk to who could provide them with practical support; (3) Integration and parity of physical and mental health care; (4) The intervention being sufficient to meet their needs and quick to access. Discussion Participants found the intervention feasible and acceptable. A drop-in centre in a paediatric hospital appears to be a positive and valued adjunct to supplement existing mental health services at GOSH.

Actigraphy, an objective measure of motor activity, reliably indexes increased movement levels in attention-deficit/hyperactivity disorder (ADHD) and may be useful for diagnosis and treatment-monitoring. However, actigraphy has not been examined in complex neurodevelopmental conditions. This study used actigraphy to objectively measure movement levels in individuals with a complex neurodevelopmental genetic disorder, tuberous sclerosis (TSC). Thirty participants with TSC (11–21 years, 20 females, IQ = 35–108) underwent brief (approximately 1 h) daytime actigraph assessment during two settings: movie viewing and cognitive testing. Multiple linear regressions were used to test associations between movement measurements and parent-rated ADHD symptoms. Correlations were used to examine associations between actigraph measures and parent-rated ADHD symptoms and other characteristics of TSC (symptoms of autism spectrum disorder (ASD), intellectual ability (IQ), epilepsy severity, cortical tuber count). Higher movement levels during movies were associated with higher parent-rated ADHD symptoms. Higher ADHD symptoms and actigraph-measured movement levels during movies were positively associated with ASD symptoms and negatively associated with IQ. Inter-individual variability of movement during movies was not associated with parent-rated hyperactivity or IQ but was negatively associated with ASD symptoms. There were no associations with tuber count or epilepsy. Our findings suggest that actigraph-measured movement provides a useful correlate of ADHD in TSC.

The coronavirus pandemic has highlighted the need for remote technologies to be used in child and adolescent mental health services. With the UK being placed in lockdown one week before a scheduled 'face-to-face' low-intensity CBT training day due to COVID-19, there was a need for rapid adaptations to be made to the content, structure and format of a training day for practitioners in mental health services, to suit the online environment. The content covered the core areas of low-intensity CBT in children and adolescents. Findings showed that the one-day low-intensity training day increased knowledge and understanding in all key areas measured, and was positively received, providing further evidence for the effectiveness and acceptability of remote delivery. Given discussed benefits of remote delivery, as well as rapid developments in technologies helping to address some of the challenges raised, going forward, remote delivery could continue to be beneficial for increasing access to much needed evidence-based interventions.

Aim: To investigate the interdependence between risk factors associated with long-term intellectual development in individuals with tuberous sclerosis complex (TSC). Method: The Tuberous Sclerosis 2000 Study is a prospective longitudinal study of individuals with TSC. In phase 1 of the study, baseline measures of intellectual ability, epilepsy, cortical tuber load, and mutation were obtained for 125 children (63 females, 62 males; median age=39mo). In phase 2, at an average of 8 years later, intellectual abilities were estimated for 88 participants with TSC and 35 unaffected siblings. Structural equation modelling was used to determine the risk pathways from genetic mutation through to IQ at phase 2. Results: Intellectual disability was present in 57% of individuals with TSC. Individuals without intellectual disability had significantly lower mean IQ compared to unaffected siblings, supporting specific genetic factors associated with intellectual impairment. Individuals with TSC who had a slower gain in IQ from infancy to middle childhood were younger at seizure onset and had increased infant seizure severity. Structural equation modelling indicated indirect pathways from genetic mutation, to tuber count, to seizure severity in infancy, through to IQ in middle childhood and adolescence. Interpretation: Early-onset and severe epilepsy in the first 2 years of life are associated with increased risk of long-term intellectual disability in individuals with TSC, emphasizing the importance of early and effective treatment or prevention of epilepsy. What this paper adds: Intellectual disability was present in 57% of individuals with tuberous sclerosis complex (TSC). Those with TSC without intellectual disability had significantly lower mean IQ compared to unaffected siblings. Earlier onset and greater severity of seizures in the first 2 years were observed in individuals with a slower gain in intellectual ability. Risk pathways through seizures in the first 2 years predict long-term cognitive outcomes in individuals with TSC.

Rates of psychiatric disorders are considerably elevated in young people with long term physical health conditions. Currently few children obtain effective mental health treatments in the context of long term physical health conditions, and ways to improve access to evidence-based mental health interventions are urgently needed. One approach is to deploy briefer, more economical, yet still evidence-based, treatments. The objective of this review was to evaluate the efficacy of brief interventions targeting psychiatric disorders in children and young people with long term physical health conditions.Predefined terms relating to brief psychological interventions for psychiatric disorders in children with long term physical health conditions were used to search relevant databases. A systematic review and meta-analysis was carried out in accordance with the Cochrane guidelines. Two reviewers independently screened titles and abstracts, extracted the data and conducted risk of bias assessments.A total of 12 randomised controlled trials were found to meet the inclusion criteria of the review. Of those, three studies were suitable for meta-analysis. A large effect size in favour of brief cognitive behavioural therapy for anxiety was found (g = - 0.95, CI -1.49 to -0.041; p .001) with non-significant moderate-substantial heterogeneity (IThis review suggests there is preliminary evidence that brief interventions, based on cognitive behavioural principles, may benefit young people with an anxiety disorder in the context of a long term physical health condition. There was insufficient evidence to assess whether this held true for depression and disruptive behaviour.

Background Young people with a physical illness are at significantly greater risk of developing emotional and behavioural difficulties. Such problems may also have negative consequences on the management and course of the physical illness itself. This study was part of a broader project to examine the acceptability, feasibility and impact of a Mental Health and Psychological Wellbeing Drop-in Centre in a hospital setting. The aims of this particular pilot investigation were: (i) to establish whether there is a need for such a resource amongst the hospital’s patient population, (ii) to characterise the nature and severity of symptoms amongst patients presenting to the centre, and (iii) to establish the types of support that are requested and/or most needed. Methods A drop-in ‘booth’ located in the reception of Great Ormond Street Hospital (GOSH) was run by clinicians and researchers over the course of one week (Monday to Saturday), serving as a focus for recruitment and space for treatment, with a Clinical Psychologist or Psychiatrist on-call throughout. Basic demographic data were gathered and symptom severity measured using standardised emotional and behavioural difficulties questionnaires (SDQ, GAD-7 and PHQ-9). Results 31 participants were recruited from 28 families. The median age of young people presenting was 9 years (IQR: 6.5–11); 47% identified as White British and 55% were male. Primary problems identified included: anxiety (45%), challenging behaviour (31%) and low mood (21%). Whilst 75% of young people recruited were in the clinical range with respect to scores on the SDQ, 50% and 30% of parents scored in the clinical range for anxiety and depression, respectively. 32% of families reported never having received mental health input for their child. Conclusion A considerable proportion of patients and family members attending GOSH met the clinical threshold for common mental health problems, indicating a potential, as yet unmet, need.

Background Many children with physical illness also have emotional or behavioural difficulties. These may impact significantly on the individual and family and may have consequences on the management and course of the physical illness. Psychological assessments and interventions have the potential to improve both mental and physical health outcomes in young people in a hospital setting. Aims This study is part of a broader project evaluating the provision of early intervention for mental health difficulties in the form of a Mental Health and Psychological Wellbeing Drop-in Centre situated in GOSH reception. As GOSH is a research hospital, understanding optimal recruitment strategies is of critical importance. In this study, we aimed to evaluate such strategies. Methods Researchers and trained GOSH volunteers recruited participants in reception and outpatient clinics over the course of a month. Additionally, a public information talk was given as a means of promoting mental health. Researchers used a recruitment log to measure perceived interest in the project and explored the effects of varying the method, time, day and location of recruitment on the volume of participants consented. Results Twenty six participants have been consented to date. Preliminary analyses suggest that there was no significant difference in volume of participants consented as a function of time or day, but indicate a potential benefit of recruiting from across multiple locations in parallel. Child friendly activities, such as colouring and stickers, promoted the research to younger children and allowed parents space to talk whilst their child was occupied. Conclusion As an ongoing study, further analyses will be conducted with a larger sample. The findings will inform recruitment strategies employed throughout the broader research project, and a result, increase patient access to psychological support within the hospital. Additionally, the findings are of broader relevance to other research projects recruiting within the hospital.

Background: Attention deficit hyperactivity disorder is increased in children with intellectual disability. Previous research has suggested stimulants are less effective than in typically developing children but no studies have titrated medication for individual optimal dosing or tested the effects for longer than 4 weeks. Method: One hundred and twenty two drug-free children aged 7-15 with hyperkinetic disorder and IQ 30-69 were recruited to a double-blind, placebo-controlled trial that randomized participants using minimization by probability, stratified by referral source and IQ level in a one to one ratio. Methylphenidate was compared with placebo. Dose titration comprised at least 1 week each of low (0.5 mg/kg/day), medium (1.0 mg/kg/day) and high dose (1.5 mg/kg/day). Parent and teacher Attention deficit hyperactivity disorder (ADHD) index of the Conners Rating Scale-Short Version at 16 weeks provided the primary outcome measures. Clinical response was determined with the Clinical Global Impressions scale (CGI-I). Adverse effects were evaluated by a parent-rated questionnaire, weight, pulse and blood pressure. Analyses were by intention to treat. Trial registration: ISRCTN 68384912. Results: Methylphenidate was superior to placebo with effect sizes of 0.39 [95% confidence intervals (CIs) 0.09, 0.70] and 0.52 (95% CIs 0.23, 0.82) for the parent and teacher Conners ADHD index. Four (7%) children on placebo versus 24 (40%) of those on methylphenidate were judged improved or much improved on the CGI. IQ and autistic symptoms did not affect treatment efficacy. Active medication was associated with sleep difficulty, loss of appetite and weight loss but there were no significant differences in pulse or blood pressure. Conclusions: Optimal dosing of methylphenidate is practical and effective in some children with hyperkinetic disorder and intellectual disability. Adverse effects typical of methylphenidate were seen and medication use may require close monitoring in this vulnerable group. © 2012 Association for Child and Adolescent Mental Health.

OBJECTIVES: To examine the prevalence of bullying behavior in adolescents from Cape Town and Durban, South Africa, and the association of these behaviors with levels of violence and risk behavior. METHOD: Five thousand and seventy-four adolescent schoolchildren in grade 8 (mean age 14.2 years) and grade 11 (mean age 17.4 years) at 72 Government schools in Cape Town and Durban, South Africa completed self-report questionnaires on participation in bullying, violent, anti-social and risk behaviors. RESULTS: Over a third (36.3%) of students were involved in bullying behavior, 8.2% as bullies, 19.3% as victims and 8.7% as bully-victims (those that are both bullied and bully others). Male students were most at risk of both perpetration and victimization, with younger boys more vulnerable to victimization. Violent and anti-social behaviors were increased in bullies, victims and bully-victims compared to controls not involved in any bullying behavior (p

Objective Familial risk for depression results from both biological and social influences. These may also be associated with other characteristics, including alcohol use, smoking, and body mass index (BMI), and with environmental risks such as social problems, life events, and educational level, all of which may be associated with depression in offspring. The authors examined the links between (1) parental familial vulnerability to depression and (2) the role of associated parental characteristics on severe adolescent depressive symptoms. Third, the authors explored the influence of family environment variables. Fourth, the authors sought interactions between parental familial vulnerability and family environment. Method Questionnaires were obtained from 1,294 parents of 1,818 adolescent offspring. Results The odds of severe adolescent depressive symptoms increased by a factor of 1.5 per standard deviation increase in parental familial vulnerability to depression (odds ratio [OR] = 1.50). Parental BMI (OR = 1.05) and educational level (OR = 2.60) had significant influences independent of parental vulnerability. Analyses indicated a significant interaction such that those with high parental familial vulnerability, whose parents also had no qualifications, had a threefold risk of severe depressive symptoms. Conclusions Adolescents with a family history of depression whose parents also lack qualifications may be a target for intervention.

Background Paediatric obsessive-compulsive disorder (OCD) often goes undetected, delaying access to evidence-based treatment. This study aimed to assess the utility of a computerised diagnostic tool, the Development and Well-Being Assessment (DAWBA), in detecting OCD and comorbidity in youth. Method A total of 51 young people referred to a specialist OCD service between September 2007 and July 2008 completed the DAWBA prior to clinical assessment. Computer-rated and clinician-rated DAWBA diagnoses were compared with those assigned by the specialist clinic. Results The computer-rated and clinician-rated DAWBA correctly classified OCD in 71% and 77% of cases respectively. Compared to consensus diagnoses, the computer-rated DAWBA tended to over-diagnose comorbidity, while the clinician-rated DAWBA diagnoses of comorbidity corresponded well with the consensus. Conclusions The DAWBA has potential value in detecting OCD as well as comorbid disorders, and could be a cost-effective method for diagnosing OCD and related problems.

This study aimed to identify whether nonparental preschool childcare was associated with adolescent mental health outcomes as measured by the strengths and difficulties questionnaire (SDQ).This study was a secondary analysis of data from the Croydon Assessment of Learning Study. From a general population sample of 2,726 adolescents tested for cognitive ability, additional data were collected from a stratified sub-sample of 197 subjects. A semi-structured interview asked parents about preschool childcare and early development concerns. Parent and teacher SDQ and IQ data were collected. Complete data were available from 167 subjects. Using nonparental preschool childcare as the 'treatment' effect and parental childcare as the 'control', propensity score matching analyses were used to analyse the effect of nonparental childcare on adolescent SDQ outcomes.Nonparental childcare was reported by 49% of the sample and was not significantly associated with conduct, emotional, peer or prosocial SDQ subscales, but was found to have a significant average treatment effect on symptoms of attention/hyperactivity, on average raising the symptom subscale score by 1.8 (95% confidence interval 0.12-3.65). The propensity score analysis ensures the results could not be explained by the available measures that influenced receiving nonparental care. Increased time spent in nonparental childcare was associated with greater attention/hyperactivity symptoms.Nonparental preschool care showed little association with generalized psychopathology but may be associated with hyperactivity and inattention problems. Replication of these findings in prospective studies is required.

To document and compare prevalence rates of adolescent injury-related risk behaviours at six sites in South Africa.The identical self-administered instrument was used at all sites. Prevalence rates (with 95% confidence intervals) were calculated taking the multistage cluster sampling strategy into account.In Cape Town, Durban, Port Elizabeth and Mankweng participants were drawn from either grades 8 or 9, and grade 11, while in Queenstown and Umtata they were drawn from grade 11 only. We selected 39 schools in Cape Town and Durban, 33 in Port Elizabeth and 20 in each of the rural areas.Road-related risk behaviour, violence, and suicide attempts.Across the sites there were high rates of risk behaviour in all domains. For example, in the 12 months preceding the survey an estimated 52.8% of grade 11 males in Cape Town had travelled in the front seat of a motor vehicle without a seatbelt, 33.0% of grade 8 males in Mankweng had bullied others, while 44.5% of the same group had been bullied, and 18.6% of females in Port Elizabeth had attempted suicide. Rates were lower in rural areas for behaviour involving motor vehicles, but there were no consistent urban-rural findings for violence-related behaviour. Females were at higher risk of suicidal behaviour and males were at higher risk of other injury-related behaviour.There is a need for effective interventions to reduce the extent of injury-related risk behaviour in adolescents in urban and rural settings.

The monozygotic (MZ) twin differences method was used to examine nonshared environmental aspects of the association of parenting (punitive and constructive discipline), negative life events (independent and dependent), and peers (antisocial and prosocial) with adolescent depressive symptoms in terms of sequelae, risk, and maintaining factors. Two self-report booklets were completed by 328 MZ twin pairs aged 12-19 years, 6 months apart. Increased punitive discipline and negative life events were found to be relevant nonshared environmental factors that followed depression. Negative life events were the only factor that had a direct nonshared environmental association with concurrent depressive symptoms in adolescents independent of previous depressive symptoms, and all other study variables.

Aims: A study was undertaken to investigate suicide rates and proportional mortality trends in South Africa from 1968 to 1990. Methods: Suicide rates per 100,000 population per year and suicide proportional mortality rates per year were calculated. The analyses were stratified by race, sex, and age group. Trends were interpreted using graphs depicting smoothed sex/race-specific suicide rates and proportional mortality rates over time. Regression models for suicide rates were fitted within specific age groups to test the effects of race, sex, and time. Further analysis was done within the specific age and race groups, if any interaction was found with time. Results: There were increases in suicide rate in the young (particularly for white males) and for whites aged 65 years and above (particularly for males). Conclusions: The finding that suicide among the young and elderly in South Africa is increasing suggests that preventive efforts are indicated, especially for white males. Trends for young South Africans mirror those in Europe and the USA, and attention to trends in these countries may predict future trends in youth suicide in South Africa.

Background: Poor school attendance has negative consequences for the individual and society. We investigated physical and mental health correlates of school attendance amongst black children in Cape Town, South Africa. Methods: We undertook a cross-sectional community study of children, aged 6–16 years, living in Khayelitsha township. Multistage sampling produced a sample of 499 children. They, and/or their parents, were interviewed using a Xhosa translation of the Diagnostic Interview Schedule for Children Version 2.3 (DISC-2.3). Prevalence of mental and physical health problems of school attenders were compared with those of non-attenders. Results: 23.6 % of children were not attending school. Young children from unserviced areas were at particular risk. Male school attenders suffered higher levels of chronic illness than non-attenders. No differences in the prevalences of psychiatric disorders were found. Conclusions: There is no significant excess of physical or mental health problems in out of school children. Poverty plays an important role in failure to attend school.

Functional MRI neurofeedback (fMRI-NF) could potentially be a novel, safe nonpharmacological treatment for attention deficit hyperactivity disorder (ADHD). A proof-of-concept randomized controlled trial of fMRI-NF of the right inferior frontal cortex (rIFC), compared to an active control condition, showed promising improvement of ADHD symptoms (albeit in both groups) and in brain function. However, comparison with a placebo condition in a larger trial is required to test efficacy.This double-blind, sham-controlled randomized controlled trial tested the effectiveness and efficacy of fMRI-NF of the rIFC on symptoms and executive functions in 88 boys with ADHD (44 each in the active and sham arms). To investigate treatment-related changes, groups were compared at the posttreatment and 6-month follow-up assessments, controlling for baseline scores, age, and medication status. The primary outcome measure was posttreatment score on the ADHD Rating Scale (ADHD-RS).No significant group differences were found on the ADHD-RS. Both groups showed similar decreases in other clinical and cognitive measures, except for a significantly greater decrease in irritability and improvement in motor inhibition in sham relative to active fMRI-NF at the posttreatment assessment, covarying for baseline. There were no significant side effects or adverse events. The active relative to the sham fMRI-NF group showed enhanced activation in rIFC and other frontal and temporo-occipital-cerebellar self-regulation areas. However, there was no progressive rIFC upregulation, correlation with ADHD-RS scores, or transfer of learning.Contrary to the hypothesis, the study findings do not suggest that fMRI-NF of the rIFC is effective in improving clinical symptoms or cognition in boys with ADHD.