Eating disorders, weight perception, and dieting in adolescence

Background: Eating disorders are serious psychiatric disorders, which usually have their onset in adolescence. Body dissatisfaction and dieting, both common among adolescents, are recognised risk factors for eating disorders. The aim of the present study was to assess the prevalence of eating disorders in the general adolescent population, assess the risk of developing eating disorders in subgroups of dieters, and analyse longitudinal concomitants of incorrect weight perception. Method: A prospective follow-up study on 595 adolescents, aged 15 at baseline, was conducted in western Finland. The study comprised questionnaires directed at the whole study population and subsequent personal interviews with adolescents found to be screen-positive for eating disorders, at both baseline and three-year follow-up. Results: The lifetime prevalence rates for 18 year old females were 2.6 % for anorexia nervosa, 0.4 for bulimia nervosa, and 9.0 % for eating disorder not otherwise specified (EDNOS). No prevalent case of DSM-IV eating disorders was found among the male participants. Eating disorders, as well as depressive symptoms, social anxiety, and low self-esteem, was more prevalent among females who perceived themselves as being overweight, despite being normal or underweight, when compared to females with a correct weight perception. An incorrect weight perception was associated in males with social anxiety. Female adolescents dieting due to psychological distress, rather than vanity or overweight, had a fifteen-fold risk of developing an eating disorder. Conclusions: Eating disorders are common among female adolescents, and adolescents choosing to diet due to psychological distress show a markedly increased risk of developing an eating disorder. Promotion of general well-being as well as the prevention of body dissatisfaction and misdirected dieting, accompanied by early detection and proper treatment of eating disorders, is needed to reduce the incidence of and facilitate recovery in adolescents suffering from eating disorders.

Adoption of information technology based patient education in psychiatric nursing

The overall goal of the study was to describe adoption of information technology (IT)-based patient education (PE) developed for patients and nurses use in psychiatric nursing. The data were collected in three phases during the period 2000-2006 in a variety of psychiatric settings in Finland. Firstly, the development process of IT-based PE for patients with schizophrenia spectrum psychosis was described. Secondly, nurses’ adoption of IT-based PE and the variables explaining adoption were demonstrated. Moreover, use of daily IT-based PE in clinical practice and factors associated with use were identified and described. And thirdly, nurses’ experiences of the IT-based PE after one year clinical use were evaluated. IT-based PE program was developed in several stages based on users’ needs and it included information and multimedia applications. Altogether, almost 500 IT-based PE sessions were carried out by the nurses on the study wards and revealed nurses’ activity in educating patients using IT to vary and depend on the hospital in which they worked. Almost 80% of all the possible IT-based PE sessions involved 93 patients and 83 nurses. Less than 2% of the IT-based PE sessions were interrupted and less than 10% suffered disturbances due to the patients or external causes. Moreover, the patients whose education took more days had poorer mental status than those whose education was carried out over a shorter period. After a year’s experience, advantages and disadvantages were described by the nurses for both patients and nurses of the IT-based PE. IT-based PE can be used even on closed acute psychiatric wards with patients with serious mental health disorders. However, technology adoption requires time, and therefore, it must fit in with clinical practice. Collaboration between users and developers is needed when developing user-centered methods in the area of mental health services. Moreover, it is important to understand factors that affect IT adoption in healthcare settings. IT-based PE is one option in interactive and co-operative health care practice between patients and nurses. Therefore the staff should begin to refer patients to established, credible and well-maintained Internet sites that provide information on common psychological problems. Even if every nurse should be trained and engaged to carry out IT-based PE, by targeting the training especially for the most active nurses aids them to support the less active ones. Adoption should also be understood from a perspective that includes aspects related to the context where it is implemented and examine how and in what circumstances it works.

Aggression and its Management in Adolescent Forensic Psychiatric Care

The overall goal of this study was to explore and identify good aggression management methods and on that basis to produce recommendations for aggression management in the adolescent forensic setting. The study was conducted in three phases. In Phase I, staff’s (n = 58) perception of adolescent aggressive behaviour and methods to manage it was examined. In Phase II, staff’s (n = 30) perception of treatment settings and treatment interventions available were studied. In Phase III, the effectiveness of an aggression management programme was evaluated. The data were collected during the period 2004-2007. Participants perceived adolescent aggressive behaviour in a similar way and described aggressive behaviour as being a comprehensible phenomenon. Management methods used to control aggressive situations were alike, although the practical solutions varied between the study units, especially regarding coercive methods. Staff members proposed more time and better opportunities to discuss and evaluate the aggression situation in order to improve the methods used. The treatment settings were similar in studied forensic units and interventions were primarily focused on psychological aspects, including management of aggressive behavior. A comprehensive aggression management programme proved to be effective in decreasing incidents of violence. The use of coercive methods in aggression situations decreased and injuries to the staff became less frequent. If staff members intend to apply high quality management methods in aggression situations they have to share a consistent understanding of aggressive behaviour and need to be aware of the various methods available. In addition, they should learn more about assessment methods in order to improve aggression management. International comparison of aggression, methods for managing it and service provision creates a starting point for developing equal care provision and realization within and between European countries.

Containment Measures in Adolescent Psychiatric Care - Focus on Mechanical Restrain

Rajoitetoimet, erityisesti sitominen, nuorisopsykiatrisessa hoitotyössä Tutkimuksen tavoitteena oli kuvata ja syventää tietoa rajoitetoimien, erityisesti sitomisen, käytöstä nuorisopsykiatrisessa vastentahtoisessa osastohoidossa. Tutkimuksen tavoitteena oli kuvata hoitajien, lääkäreiden ja potilaiden asenteita eri rajoittamiskeinoja kohtaan nuorisopsykiatrisessa osastohoidossa, kerätä tietoa yhden vuoden aikana tapahtuneiden sitomisten määrästä ja luonteesta sekä kuvata potilaiden kokemuksia sitomisesta nuorisopsykiatrisen osastohoidon aikana. Tutkimus tuottaa arvokasta tietoa korkeatasoisten sitomiskäytäntöjen kehittämiseen nuorisopsykiatrisessa osastohoidossa, sekä sitomisten määrää vähentämällä että sitomistapoja kehittämällä. Tavoitteena on parantaa sidottujen potilaiden kliinistä hoitoa. Tutkimusaineisto kerättiin suomalaisilla, pääkaupunkiseudulle sijoittuvilla, nuorisopsykiatrisilla osastoilla neljässä vaiheessa lokakuun 2009 ja huhtikuun 2012 välisenä aikana. Helsingin ja Uudenmaan sairaanhoitopiirin (HUS) nuorisopsykiatrian erikoisalan seitsemän suljetun osaston hoitohenkilökunta sekä lääkärit suhtautuivat myönteisesti rajoittamistoimenpiteisiin. Nuorisopsykiatriset potilaat suhtautuivat rajoittamistoimenpiteisiin kriittisemmin kuin henkilökunta. Nuoret suhtautuivat myönteisimmin tarvittaessa annettavaan lääkitykseen, ajoittaiseen tarkkailuun ja kulun rajoittamiseen. Vähiten hyväksytty menetelmä oli verkkosänky. Nuoret arvioivat sitomisen kolmen vähiten hyväksytyn menetelmän joukkoon. Sitomisen esiintyvyys ja pitkien sitomisten määrä olivat korkeita tutkimukseen valituissa yksiköissä. Useimmat sidotut nuoret tiesivät syyn sitomiseensa, suhtautuivat siihen ambivalentisti nähden siinä sekä hyötyä että haittaa, pitäen sitä kuitenkin rangaistuksena. Huolimatta tästä, suurin osa haastatelluista nuorista koki, että joissain tilanteissa sitomista tarvitaan nuorisopsykiatrisessa osastohoidossa. Nuorilla oli monia ehdotuksia, kuinka parantaa sitomista käytännön osastohoidossa. Tämä väitöskirja tuottaa uutta tietoa eri rajoittamistoimenpiteiden ja sitomisen toteuttamisesta nuorisopsykiatrisessa osastohoidossa. Käytännön hoitotyön parantamiseksi nuorisopsykiatrisilla osastoilla tarvitaan laaja-alaista ja syvälle luotaavaa koulutusta, jotta rajoittamis-toimenpiteiden määrää voidaan vähentää. Myös kriisitilanteiden hallintaan tarvitaan uusia keinoja. Tietoa, kuvausta toimenpiteistä ja tilanteiden käsittelyä jälkikäteen tulee tarjota ala-ikäiselle potilaalle hänen kehitystasonsa huomioiden. Sitomisten määrää tulee vähentää ja niiden kestoa lyhentää. Nuorten tulee olla aktiivisesti mukana kehittämässä aggression hallintamenetelmiä suomalaisessa nuorisopsykiatrisessa osastohoidossa.

Coercion, Perceived Care and Quality of Life Among Patients in Psychiatric Hospitals

The goals of the study were to describe patients’ perceptions of care after experiencing seclusion/restraint and their quality of life. The goal was moreover to identify methodological challenges related to studies from the perspective of coerced patients. The study was conducted in three phases between September 2008 and April 2012. In the first phase, the instrument Secluded/ Restrained Patients’ Perception of their Treatment (SR-PPT) was developed and validated in Japan in cooperation with a Finnish research group (n = 56). Additional data were collected over one year from secluded/restrained patients using the instrument (n = 90). In the second phase, data were collected during the discharge process (n = 264). In the third phase, data were collected from electronic databases. Methodological and ethical issues were reviewed (n = 32) using systematic review method. Patients perceived that co-operation with the staff was poor; patients’ opinions were not taken into account, treatment targets collated and treatment methods were seen in different ways. Patients also felt that their concerns were not well enough understood. However, patients received getting nurses’ time. In particular, seclusion/restraint was considered unnecessary. The patients felt that they benefited from the isolation in treating their problems more than they needed it, even if the benefit was seen to be minor. Patients treated on forensic wards rated their treatment and care significantly lower than in general units. During hospitalization secluded/restrained patients evaluated their quality of life, however, better than did non-secluded/restrained patients. However, no conclusion is drawn to the effect that the better quality of life assessment is attributable to the seclusion/restraint because patients’ treatment period after the isolation was long and because of many other factors, as rehabilitation, medication, diagnostic differences, and adaptation. According to the systematic mixed studies review variation between study designs was found to be a methodological challenge. This makes comparison of the results more difficult. A research ethical weakness is conceded as regards descriptions of the ethical review process (44 %) and informed consent (32 %). It can be concluded that patients in psychiatric hospital care and having a voice as an equal expert require special attention to clinical nursing, decision-making and service planning. Patients and their family members will be consulted in plans of preventive and alternative methods for seclusion and restraint. The study supports the theory that in ethical decision-making situations account should be taken of medical indications, in addition to the patients’ preferences, the effect of treatment on quality of life, and this depends on other factors. The connection between treatment decisions and a patient’s quality of life should be evaluated more structurally in practice. Changing treatment culture towards patients’ involvement will support daily life in nursing and service planning taking into account improvements in patients’ quality of life.

Evaluation of an e-learning course: coercion practices in psychiatric nursing

The goal of the study was to evaluate an e-learning course entitled “Nursing interventions to manage distressed and disturbed patients” and intended for psychiatric nurses, using Kirkpatrick’s evaluation model. The aim was to describe nurses’ reactions, learning, behaviour change and impacts resulting from this e-learning course. This dissertation comprises four papers, and the data were collected 2008-2012 from three different sources; electronic databases, an e-learning platform and psychiatric hospitals. First, a systematic literature review was conducted to understand the effectiveness of e-learning. Second, an RCT study was implemented to investigate the impact of the e-learning course on nurses’ job-satisfaction, knowledge and attitudes (N=158). Third, to complete the picture of nurses views of the e-learning course related to knowledge transfer, the nurses’ perspective was studied (N=33). Lastly, the effects of the e-learning course from nursing managers’ perspective in psychiatric hospital organisations were studied (N=28). The systematic review showed that although the nurses were satisfied with the e-learning, no effects were found in the RCT study of nurses’ job satisfaction. The RCT study showed no effects on nurses’ learning related to knowledge increase, but there was change in attitudes. The managers described the changes in the nurses’ knowledge and attitudes. Among the nurses behaviour changed with knowledge transfer from the e-learning course to practice and they pointed out development issues related to their work. The final impacts of the e-learning course revealed advantages and disadvantages of the e-learning course and its implications for nurses’ work. This dissertation provides new insight into nurses’ reactions, learning, behaviour change and impacts resulting from an e-learning course in their continuing education. In order to improve nurses’ continuing education systematic evaluation is needed, for which Kirkpatrick’s evaluation model is a useful tool.

Children at psychiatric risk and their families in Bucharest, in the context of 25 years of changes after December 89’ Romanian Revolution

The aim of the present dissertation was to capture a picture of child and adolescent mental health in Romania, in the context of almost 25 years of changes following the Romanian Revolution of December ’89. A three-part study was carried out in order to provide consistent answers to the pre-defined objectives: to appraise the development of child and adolescent mental health services in Romania (Part I), to explore the characteristics of clinically-referred patients in a Romanian child and adolescent psychiatry department (Part II), to examine the children’s mental health state and its connections with family functioning and associated risk factors (Part III). A multi-method research approach was used, comprising one qualitative analysis and two quantitative research studies. Part I consisted of a comparative qualitative analysis of the answers given by 10 mental health professionals at a 12-questions open ended interview about the current situation in child and adolescent mental health in Romania, on three topics: changes, challenges, solutions. Part II involved a descriptive quantitative analysis of certain variables (e.g. age, gender, primary diagnosis, co-morbidities, time of hospitalization) conducted on the patients who had been admitted to the Child and Adolescent Psychiatry Department at “Prof. Dr. Alexandru Obregia” Psychiatry Hospital, Bucharest in 1991 and in 2013. Part III was conducted on 342 subjects enrolled in two clinical groups and one school group, this study being performed through a cross-sectional analysis on multi-informant child and adolescent mental health problems and competencies (CBCL, YSR, SDQ P, SDQ SR) and their interrelation with household information (HQ) and family functioning (FAD). Outlining the results it can be stated that: 1) The CAMH System in Romania is definitely set on the path of reorganization, including a higher involvement of beneficiaries and of the community. 2) The characteristics of the admitted patients have changed significantly during the last almost 25 years since `89 December Revolution, under the influence of word wide trends in child psychiatry and of administrative aspects of the mental health network in Romania. 3) The rates of main diagnoses and co-morbidities confirm the reports in literature, with Autism Spectrum Disorder being the most frequent childhood psychiatric disorders in this study. 4) The children’s mental health problems in the psychiatry group are comparable to those reported for other clinical populations. 5) Significant score differences were observed according to various household features and also meaningful associations between a child’s clinical status and different aspects of family functioning. The Romanian Child and Adolescent Psychiatry has started to adopt the norms and standards of the European Union. In the 25 years that have elapsed after the 1989 Revolution, many changes have occurred in Romanian CAMH, but many unresolved issues have also risen. Therefore, the major contribution of this thesis is that it provides a coherent and updated overview of the present-day situation from three different perspectives- those of mental healthcare professionals, the one observed in clinical patients and the one reported by children’s families.

International adoption: Symptoms of attachment disorders and their associations with the child’s background and developmental outcome

Many internationally adopted children have lived their first years of life in an environment with limited opportunities for primary caregiving. The lack of consistent care increases the prevalence of attachment disorders among them. Less is known about the influences of attachment disorders on a child’s later course of life. This study is part of the Finnish Adoption Study. Parents of all Finnish children who had been internationally adopted by legal adoption organisations between 1985 and 2007 were sent questionnaires (N=1450). Parental evaluations of the children’s symptoms of reactive attachment disorder (RAD) at the time of adoption, their later learning or language problems using a screening scale, and children’s self-reported school bullying experiences were evaluated. Each child’s attachment-related behavioural problems were requested in a follow-up survey 1.9 and 3.8 years after adoption and compared with a Finnish reference group. This study indicated that Finnish internationally adopted children have at least three-fold prevalence of learning and language problems compared with their age-mates. A child’s symptoms of attachment disorders were associated with learning or language problems at school age as well as with his/her school bullying experiences. The adopted children had more attachment-related behavioural problems two years after adoption than their age-mates, but the difference was no longer evident four years after adoption. In conclusion, this study showed that the symptoms of attachment disorder indicate a risk for an adopted child’s later developmental outcome. The findings demonstrate the need for comprehensive clinical examinations and planning of treatment strategies for children with symptoms of RAD.