The number of presenting psychiatric emergencies has increased over the last 10 years. Comparing symptoms from 2003 and 2006 showed a significant rise in their severity. This study highlights the need for 24-h access for acute evaluation by physicians skilled in child and adolescent psychiatry, and raises concern that the severity could increase.

The objective of this study is to assess (1) the concordance and validity of schizophrenia register diagnoses among children and adolescents (early onset schizophrenia = EOS) in the Danish Psychiatric Central Research Register (DPCRR), and (2) the validity of clinical record schizophrenia diagnoses. Psychiatric records from 200 patients with a first-time diagnosis of schizophrenia (F20.x) at age < 18 years between 1994 and 2009 in the DPCRR were rated by experienced clinicians according to ICD-10 criteria, using a predefined checklist. We retrieved 178 records, representing 19.6% of all patients diagnosed with EOS from 1994 to 2009. Mean age was 15.2 years and 56.2% were males. The register-based and clinical diagnoses matched in 158 cases (88.8%). Raters' diagnoses confirmed the DPCRR schizophrenia diagnoses in 134 cases, rendering a diagnostic validity of 75.3% of DPCRR schizophrenia, while 149 cases were confirmed as being in the schizophrenia spectrum (83.7%). When removing records with registration errors, 83.5% of cases were confirmed as schizophrenia and 91.8% as being in the schizophrenia spectrum. Interrater reliability was substantial with Cohen's kappa > 0.78-0.83 depending on classification. Compared to diagnoses made in outpatient settings, EOS diagnoses during hospitalizations were more likely to be valid and had fewer registration errors. Diagnosed in inpatient settings, EOS diagnoses are reliable and valid for register-based research. Schizophrenia diagnosed in children and adolescents in outpatient settings were found to have a high number of false-positives, both due to registration errors and diagnostic practice. Utilizing this knowledge, it is possible to reduce the number of false-positives in register-based research of EOS.

Background Cognitive behavioural therapy (CBT) is the recommended first-line treatment for children and adolescents with obsessive-compulsive disorder (OCD), but evidence concerning treatment-specific benefits and harms compared with other interventions is limited. Furthermore, high risk-of-bias in most trials prevent firm conclusions regarding the efficacy of CBT. We investigate the benefits and harms of family-based CBT (FCBT) versus family-based psychoeducation and relaxation training (FPRT) in youth with OCD in a trial designed to reduce risk-of-bias. Methods This is an investigator-initiated, independently funded, single-centre, parallel group superiority randomised clinical trial (RCT). Outcome assessors, data managers, statisticians, and conclusion drawers are blinded. From child and adolescent mental health services we include patients aged 8–17 years with a primary OCD diagnosis and an entry score of ≥16 on the Children’s Yale-Brown Obsessive-Compulsive Scale (CY-BOCS). We exclude patients with comorbid illness contraindicating trial participation; intelligence quotient < 70; or treatment with CBT, PRT, antidepressant or antipsychotic medication within the last 6 months prior to trial entry. Participants are randomised 1:1 to the experimental intervention (FCBT) versus the control intervention (FPRT) each consisting of 14 75-min sessions. All therapists deliver both interventions. Follow-up assessments occur in week 4, 8 and 16 (end-of-treatment). The primary outcome is OCD symptom severity assessed with CY-BOCS at end-of-trial. Secondary outcomes are quality-of-life and adverse events. Based on sample size estimation, a minimum of 128 participants (64 in each intervention group) are included. Discussion In our trial design we aim to reduce risk-of-bias, enhance generalisability, and broaden the outcome measures by: 1) conducting an investigator-initiated, independently funded RCT; 2) blinding investigators; 3) investigating a representative sample of OCD patients; 3) using an active control intervention (FPRT) to tease apart general and specific therapy effects; 4) using equal dosing of interventions and therapist supervision in both intervention groups; 5) having therapists perform both interventions decided by randomisation; 6) rating fidelity of both interventions; 7) assessing a broad range of benefits and harms with repeated measures. The primary study limitations are the risk of missing data and the inability to blind participants and therapists to the intervention. Trial registration ClinicalTrials.gov: NCT03595098, registered July 23, 2018.

BackgroundSchizophrenia in children and adolescents are diagnosed using the same criteria as for adults, but the assessment may be more complex due to both developmental issues, premorbid difficulties and a less elaborated symptomatic presentation. There is a great scarcity of studies looking into validity of schizophrenia in children and adolescents.MethodsWe aimed to assess 1) the concordance and validity of schizophrenia register diagnoses among children and adolescents (early onset schizophrenia=EOS) in the Danish Psychiatric Central Research Register (DPCRR), and 2) the validity of clinical record schizophrenia diagnoses. Furthermore, to extract data from psychiatric records with confirmed schizophrenia in order to describe premorbid characteristics, history and symptomatology.Psychiatric records from 200 patients with a first-time diagnosis of schizophrenia (F20.x) <18 years between 1994 and 2009 in the DPCRR was randomly selected for the study. The psychiatric records were evaluated by experienced clinicians according to ICD-10 criteria, using a predefined checklist. All records were assessed by two raters and inter-rater reliability was assessed.ResultsWe were able to retrieve 178 of the 200 psychiatric records. The mean age of patients was 15.2 years, and 56.2% were male. The register-based and clinical diagnosis matched in 158 cases. In the 10.2% registration errors, the records reported schizophrenia as a rule-out tentative diagnosis in the majority of cases. Among the 158 psychiatric records with a clinical diagnosis of schizophrenia, the raters confirmed 132 records (83.5%) as schizophrenia and a total of 145 records (91.8%) as in the schizophrenia-spectrum. Interrater reliability was substantial with Cohen’s kappa >0.78–0.83. Compared to diagnoses made in outpatient settings, EOS diagnoses during hospitalizations had fewer registration errors and a higher validity between raters’ diagnosis and clinical diagnosis.Among the cases with EOS confirmed by raters, 85.8% had family history of mental disorders, 93.1% had experienced adverse life events during childhood with 46.9% having experienced trauma. Hallucinations were present in 76.9%, negative symptoms in 57.4% and formal thought disorder symptoms in 34%. Catatonic symptoms were described in 4.7% cases.DiscussionTo our knowledge, the study is the largest to date investigating validity of schizophrenia diagnosed in children and adolescents in clinical settings. The study confirms assessment of schizophrenia in children and adolescents to be complex, especially in outpatient settings. All evaluations by raters were conducted by use of psychiatric records retrospectively. As the diagnoses were made 8 - 24 years ago, it is believed to be the best method, however, the possibility exists that some cases were not confirmed due to lack of adequate description of psychopathology in the records. Furthermore, the raters were not blinded to the diagnoses, as only patients with a register diagnosis of schizophrenia were included.