Australian & New Zealand Journal of Psychiatry

In childhood, mental health problems primarily consist of behaviour and emotional problems. These affect one in every seven children (i.e. 200 000 in Australia). Left untreated, up to 50% of preschool problems continue through the childhood years. Because of their high prevalence, population-based approaches will be needed to reduce their associated burden. The aim of the present study was therefore to identify evidence-based preventive interventions for behavioural and emotional problems of children aged 0–8 years. Randomized controlled trials of preventive interventions for behavioural and emotional problems were located by searching standard clinical databases and systematic reviews. The authors determined which programmes were effective and ineffective, dividing the effective programmes into those with high or low risk of trial bias. Among effective programmes, the most promising for delivery in Australian contexts were identified, selected for their strength of evidence, sample comparability to Australia's population, and programme compatibility with Australia's service system. Around 50 preventive interventions have been evaluated in randomized controlled trials. Most targeted children's behavioural problems, and a few targeted emotional problems. Three US programmes have the best balance of evidence: in infancy, the individual Nurse Home Visitation Programme; at preschool age, the individual Family Check Up; at school age, the Good Behaviour Game class programme. Three parenting programmes in England and Australia are also worthy of highlight: the Incredible Years group format, Triple P individual format, and Parent Education Programme group format. Effective preventive interventions exist primarily for behaviour and, to a lesser extent, emotional problems, and could be disseminated from research to mainstream in Australia, ensuring fidelity to original programmes. Future research should develop programmes targeting emotional problems, and replicate effective programmes for behaviour problems in quality population translation trials. Randomized trial methods in staged roll-outs can determine population cost–benefits for children's mental health without delaying dissemination.

Carlsson has put forward the hypothesis that the positive and negative symptoms of schizophrenia are due to failure of mesolimbic and mesocortical projections consequent on hypofunction of the glutamate N-methyl-d-aspartate (NMDA) receptor. The hypothesis has been recently emphasized in this Journal that the loss of synaptic spines with NMDA receptors, which can be precipitated by stress, can explain the emergence of positive symptoms such as hallucinations and that this synapse regression involves molecules such as neuregulin and its receptor ErbB4 that have been implicated in schizophrenia. In this essay these two hypotheses are brought together in a single scheme in which emphasis is placed on the molecular pathways from neuregulin/ErbB4, to modulation of the NMDA receptors, subsequent changes in the synaptic spine's cytoskeletal apparatus and so regression of the spines. It is suggested that identification of the molecular constituents of this pathway will allow synthesis of suitable substances for removing the hypofunction of NMDA receptors and so the phenotypic consequences that flow from this hypofunction.

Objective: The aim of the present study was to examine the effect of comorbid oppositional defiant disorder (ODD) and conduct disorder (CD) on (i) symptom levels in attention-deficit–hyperactivity disorder (ADHD) and (ii) the relationship between neurocognitive impairment and ADHD symptom severity.

Method: A total of 200 6–12-year-old children with DSM-IV ADHD, combined type (ADHD-CT) were identified in a specialist ADHD clinic in metropolitan Melbourne. From this initial group, 23 were identified with ADHD without ODD/CD (ADHD alone), 22 had ADHD and ODD and 20 had ADHD and CD. All the children were medication naïve. Twenty-five healthy control children were also recruited from local primary schools. The four groups did not differ in age, gender or full-scale IQ. A cross-sectional study of parent- and teacher-reported ADHD and externalizing symptoms, spatial span, spatial working memory, visuospatial memory, spatial recognition, spatial planning and behavioural inhibition was completed.

Results: Parent-reported externalizing symptoms were higher in the ADHD + CD and ADHD + ODD groups compared to the ADHD alone group. There were no differences in neurocognitive function between children with ADHD-CT with and without ODD or CD. All the ADHD groups, however, performed worse than the healthy control group. Further, worse spatial span, spatial working memory and delayed matching to sample performance were associated with increased teacher-reported ADHD symptoms in the ADHD alone group. Also, worse spatial working memory performance was associated with increased teacher-reported ADHD symptoms in the ADHD + CD group.

Conclusions: ADHD symptom severity is associated with the magnitude of impairment in executive functions in children with ADHD alone, but these relationships can be obscured by the presence of comorbid disruptive disorders. Children with ADHD + CD may demonstrate similar associations to children with ADHD alone, suggesting a similar underlying dysfunction. ADHD + ODD, however, may be better understood as a maladaptive response to the abnormal behaviours and neurocognitive functions in ADHD.

Objective: There is no study on the quality of life (QOL) of parents of children with attention-deficit–hyperactivity disorder (ADHD), although QOL is increasingly gaining more attention and the interactions between children and their parents are bi-directional. The aim of the present study was therefore to survey the QOL of parents of children with ADHD in Hong Kong, and explore the relationships of sociodemographic and clinical variables with QOL.

Method: Seventy-seven parents of children with ADHD were consecutively selected and the sociodemographic and clinical characteristics of the parents and their children were assessed.

Results: Compared with the general population in Hong Kong, significantly lower scores in physical, psychological, social and environmental QOL domains were found in the parents of children with ADHD. On multivariate analysis, for the children with ADHD, the severity of emotional and hyperactivity/inattention symptoms, and having a comorbid pervasive developmental disorder were significantly correlated with one or more domains of QOL; while for the parents, educational level, household monthly income and having major medical conditions were significantly correlated with one or more domains of QOL.

Conclusions: Parents of children with ADHD have low QOL and research is needed to understand the underlying problems.

Objective: Young patients with frontotemporal dementia (FTD) may present with schizophrenia-like psychosis. Few studies have investigated whether FTD-like neuropathological changes are present in schizophrenia. The purpose of the present study was therefore to determine whether FTD-like abnormalities in TARDNA binding protein (TDP-43) and ubiquitin are detectable in hippocampal dentate gyrus of patients with schizophrenia and bipolar disorder. A secondary objective was to identify clinicopathological relationships of any such abnormalities.

Methods: Hippocampal sections from 12 patients (nine with schizophrenia and three with bipolar disorder) and 11 control subjects Facility from the National Neural Tissue Resource Centre, Melbourne were blindly rated for the presence or absence of normal TDP-43 staining or ubiquitin-positive neuronal inclusions within the dentate gyrus. The clinical files of all subjects were reviewed for demographic and clinical information.

Results: In three patients the normal expression of nuclear TDP-43 staining was not detected. Significantly, all three subjects presented after the age of 50 and had an adult child diagnosed with the same psychiatric disorder.

Conclusion: Abnormalities in TDP-43 nuclear expression were identified in patients with late-onset psychosis and a positive family history.

Objective: There is little knowledge on health-related quality of life (HRQOL) of injured children and adolescents after road traffic accidents (RTA). Although findings in injured adults suggest that post-traumatic stress symptoms (PTSS) may be important predictors of HRQOL, this issue has never been prospectively examined in children. The aim of the present study was therefore to prospectively assess HRQOL in children after RTA and specifically examine the impact of PTSS on HRQOL.

Method: Sixty-eight children (aged 6.5–14.5 years) were interviewed 1 month and 1 year after an RTA using the Child PTSD Reaction Index and the Toegepast Natuurwetenschappelijk Onderzoek-Academisch Ziekenhuis Leiden (TNO-AZL) Questionnaire for Children's Health-Related Quality of Life. Parents and physicians were assessed with questionnaires.

Results: Eleven children (16.2%) showed moderate to severe post-traumatic stress reactions at 1 month, and 12 children (17.6%) at 1 year. At 1 month, patients reported reduced motor functioning and autonomy and impairments in some parts of emotional functioning compared to a community sample. At 1 year all dimensions of HRQOL were within or above normal ranges. Multivariate analysis indicated that PTSS at 1 month significantly predicted HRQOL at 1 year.

Conclusions: This prospective study provides evidence for a long-term negative influence of early PTSS on HRQOL in injured children. The return of injured children to pre-injury HRQOL may therefore not only depend on optimal medical care but also on awareness and timely interventions regarding PTSS.

Objective: Social phobia can be treated by brief Internet-based cognitive behaviour therapy (CBT). Most people with social phobia, however, meet criteria for another mental disorder; this comorbidity is associated with significant disability, and cases of comorbidity may be more difficult to treat. The present study examined the impact of the Shyness programme, an Internet-based treatment programme for social phobia, on comorbid symptoms of depression and generalized anxiety disorder.

Method: Data from three randomized controlled trials using the Shyness programme to treat social phobia were reanalysed. The 211 subjects, all of whom met DSM-IV criteria for social phobia, were divided into four groups: (i) social phobia only; (ii) social phobia with elevated symptoms of depression; (iii) social phobia with elevated symptoms of generalized anxiety; and (iv) social phobia with elevated symptoms of both generalized anxiety and depression. The improvement in social phobia, depression and anxiety following Internet-based treatment for social phobia was measured.

Results: Improvement in social phobia was seen in all groups, whether comorbid or not. Significant improvements in comorbid symptoms of depression and generalized anxiety occurred even though the treatment was focused on the social phobia.

Conclusions: Brief Internet-based CBT can reduce both the target disorder as well as comorbid symptoms. These findings are consistent with evidence that unified or transdiagnostic programmes may reduce the severity of comorbid disorders and symptoms, indicating an important direction for future research.

Objective: Elevated serum levels of homocysteine have been shown to be associated with schizophrenia in some studies, but the evidence is still limited and mixed. The aim of the present study was therefore to evaluate the serum homocysteine level in Chinese in schizophrenia patients and assess its association with clinical phenotypes of the disease.

Method: A total of 250 inpatients and 250 healthy controls were identified at Kowloon Hospital and the Red Cross Blood Donation Centre, respectively. Each subject was evaluated with a structured diagnostic interview. Demographic data were collected and blood was analysed for homocysteine level. The Positive and Negative Syndrome Scale was used to grade clinical symptoms of schizophrenia. Confounding factors affecting homocysteine levels were controlled by strict exclusion criteria or statistical methods.

Results: Serum homocysteine level was elevated in Chinese schizophrenia patients. Both male (mean, 12.26 µmol L⁻¹; control, 11.40 µmol L⁻¹, p = 0.026) and female (mean, 9.61 µmol L⁻¹; control, 8.33 µmol L⁻¹, p < 0.001) patients had a higher serum homocysteine level than the healthy controls, and these differences persisted after controlling for age. There was no significant association between serum homocysteine level and duration of illness, clinical symptoms or age of onset of schizophrenia.

Conclusion: The serum homocysteine levels were elevated in both male and female Chinese schizophrenia patients. The levels were not apparently related to other clinical parameters.

Objective: Patients with schizophrenia show deficits in visuospatial working memory and visual pursuit processes. It is currently unclear, however, whether both impairments are related to a common neuropathological origin. The purpose of the present study was therefore to examine the possible relations between the encoding and the discrimination of dynamic visuospatial stimuli in schizophrenia.

Method: Sixteen outpatients with schizophrenia and 16 control subjects were asked to encode complex disc displacements presented on a screen. After a delay, participants had to identify the previously presented disc trajectory from a choice of six static linear paths, among which were five incorrect paths. The precision of visual pursuit eye movements during the initial presentation of the dynamic stimulus was assessed. The fixations and scanning time in definite regions of the six paths presented during the discrimination phase were investigated.

Results: In comparison with controls, patients showed poorer task performance, reduced pursuit accuracy during incorrect trials and less time scanning the correct stimulus or the incorrect paths approximating its global structure. Patients also spent less time scanning the leftmost portion of the correct path even when making a correct choice. The accuracy of visual pursuit and head movements, however, was not correlated with task performance.

Conclusions: The present study provides direct support for the hypothesis that active integration of visuospatial information within working memory is deficient in schizophrenia. In contrast, a general impairment of oculomotor mechanisms involved in smooth pursuit did not appear to be directly related to lower visuospatial working memory performance in schizophrenia.

Objective: The aim of the present study was to describe characteristics and post-release outcomes of Victorian homicide offenders under the Crimes (Mental Impairment and Unfitness to be Tried) Act 1997 (and/or its forerunner legislation) released from forensic inpatient psychiatric care since the development of specialist forensic services.

Method: A legal database identified subjects meeting inclusion criteria: hospitalized in forensic psychiatric care due to finding of mental impairment or unfitness to stand trial for homicide in Victoria; released into the community; and released between 1 January 1991 and 30 April 2002. Using clinical records, demographics, index offence, progress in hospital, diagnosis, psychosocial and criminological data were obtained. Outcomes (offending or readmission into secure care) were obtained from the clinical records.

Results: Of the 25 subjects, 19 (76%) were male. Primary diagnoses on admission to forensic hospital care were schizophrenia, n = 16 (64%); other psychotic disorder, n = 5 (20%); depression, n = 3 (12%); and personality disorder, n = 1 (4%). Mean time in custodial supervision was 11 years and 2 months, less for those whose offence occurred after the development of forensic rehabilitation services. In the first 3 years after release, there was a single episode of criminal recidivism, representing a recidivism rate of 1 in 25 (4%) over 3 years. Twelve subjects (48%) were readmitted at some point in the 3 year follow up.

Conclusion: There was a very low rate of recidivism after discharge, but readmissions to hospital were common. Lengths of custodial care were reduced after the introduction of forensic rehabilitation facilities. Recidivism is low when there are well-designed and implemented forensic community treatment programmes, consistent with other data suggesting a reciprocal relationship between safe community care and a low threshold for readmission to hospital, lessening re-offending at times of crisis. Further research should be directed at timing of release decisions, based on reducing identified risk factors to acceptable levels.