Adverse childhood experiences—household stressors and children’s mental health: a single centre retrospective review

ObjectiveTo determine the prevalence of reported ‘household stressor’ adverse childhood experiences (ACEs) in families of children presenting with neurodevelopmental, behavioural or emotional difficulties and to determine whether family vulnerabilities, individually or cumulatively, were associated with particular clinical symptomatology.DesignRetrospective chart review followed by statistical analysis of family stressors and clinical symptomatology.SettingA community paediatric clinic in Australia.ParticipantsAll 267 children who attended an initial paediatric appointment during 2018.Results162 (60.7%) children had been exposed to one or more household stressor ACEs, including 116 (43.4%) children exposed to parental mental illness. Behavioural disturbance occurred in 144 (53.9%) children and externalising behaviours (other than attention deficit hyperactivity disorder) were more frequent than internalising behaviours. Externalising and internalising behaviours were associated with individual and cumulative household stressor ACEs. Most other symptomatology apart from genetic/neurological conditions, autistic symptoms and some developmental delays appeared to be partially associated with ACEs.ConclusionHousehold stressor ACEs were common, frequently occurred concurrently, and were associated with much of the symptomatology, in this cohort. Parental mental illness was the most prevalent stressor and behavioural disturbance the most prevalent symptomatology. These findings may have implications for clinical practice and service provision.

In This Issue

What is delirium? How do we diagnose it? What is the difference between delirium and behavioural disturbance? Is delirium a useful clinical construct? Is behavioural disturbance a more useful clinical construct for intensivists? Can we do large-scale epidemiological assessment of behavioural disturbance given that it is not a binary state and that it cannot be diagnosed by numbers? These are fundamental questions in the practice of modern intensive care medicine given that such “states” appear to affect one-third or more of patients admitted to the intensive care unit (ICU). In this issue of Critical Care and Resuscitation, we present the first attempt to address this concept using the technique of natural language processing and applying it to electronic ICU notes by nurses, doctors and allied health staff. The findings may surprise you, fascinate you, and make you think about these concepts from a different perspective, as summarised in a thoughtful editorial by Professor Reade.

Natural language processing to assess the epidemiology of delirium-suggestive behavioural disturbances in critically ill patients

Background: There is no gold standard approach for delirium diagnosis, making the assessment of its epidemiology difficult. Delirium can only be inferred though observation of behavioural disturbance and described with relevant nouns or adjectives. Objective: We aimed to use natural language processing (NLP) and its identification of words descriptive of behavioural disturbance to study the epidemiology of delirium in critically ill patients. Study design: Retrospective study using data collected from the electronic health records of a university-affiliated intensive care unit (ICU) in Melbourne, Australia. Participants: 12 375 patients Intervention: Analysis of electronic progress notes. Identification using NLP of at least one of a list of words describing behavioural disturbance within such notes. Results: We analysed 199 648 progress notes in 12 375 patients. Of these, 5108 patients (41.3%) had NLP-diagnosed behavioural disturbance (NLP-Dx-BD). Compared with those who did not have NLP-Dx-DB, these patients were older, more severely ill, and likely to have medical or unplanned admissions, neurological diagnosis, chronic kidney or liver disease and to receive mechanical ventilation and renal replacement therapy (P < 0.001). The unadjusted hospital mortality for NLP-Dx-BD patients was 14.1% versus 9.6% for patients without NLP-Dx-BD. After adjustment for baseline characteristics and illness severity, NLP-Dx-BD was not associated with increased risk of death (odds ratio [OR], 0.94; 95% CI, 0.80–1.10); a finding robust to multiple sensitivity, subgroups and time of observation subcohort analyses. In mechanically ventilated patients, NLP-Dx-BD was associated with decreased hospital mortality (OR, 0.80; 95% CI, 0.65–0.99) after adjustment for baseline severity of illness and year of admission. Conclusions: NLP enabled rapid assessment of large amounts of data identifying a population of ICU patients with typical high risk characteristics for delirium. Moreover, this technique enabled identification of previously poorly understood associations. Further investigations of this technique appear justified.

Audit on use of PRN (pro re nata) psychotropic medication for behavioural disturbance in individuals with intellectual disability in the community

AimsPsychotropic medication is commonly used in people with Intellectual disabilities (ID). This may be attributed in part to an increased prevalence of mental illness in this population and the presence of challenging behaviour which has been shown to increase rates of prescribing. Whilst there are a number of studies looking at regularly prescribed medication there are few studies on “as and when” required (PRN) medication.Psychotropic medication continues to be used to manage behavioural disturbances in people with ID. Where there is no clear cut psychiatric illness, the role of psychotropic medication is an adjunct to a comprehensive multimodal treatment plan.The aim is to find out if prn psychotropic medication for behavioural disturbance is being used appropriately and safely in these individuals.MethodFiles and PRN protocols of individuals known to be using prn psychotropic medications for the management of acute episodes of agitation and behavioural problems and supported by professional staff teams was studied.We collected the data by contacting the residential homes, carers, Collecting details from case notes, from the Staff nurse who made the protocol for their patientsA questionnaire based on the standards mentioned above was developed and files and prn protocols were marked against these standards.ResultThe standards from the medical file were 100 % achieved. Thus indicating the importance of the psychotropic prn medication and documentation of the same.However, the protocol that needs to be with the patient/carers had some lacuna/deficits. Overall only in 53% of the case, standards were achieved. This needs to be highlighted to the team.The Audit gave an insight into what needs to be improved.THE FOLLOWING AREAS NEEDED IMPROVEMENT 1.There should be a prn protocol/ similar instruction to the staff about the use of prn medication(written by appropriately trained professional)2.Prn protocol should be accessible to direct care staff3.There should be a description of when to use the prn medication4.There should be a description of what non-pharmacological de-escalation methods ought to be tried before using prn/ is there a detailed behaviour support plan available5.Protocol should describe what the medication is expected to do6.Protocol should describe the minimum time between doses if the first dose has not worked7.Protocol should state the maximum dose in 24 hour period8.Use of prn should be recordedConclusionI hope this audit will help in improving the patient care with the right psychotropic prn medication, with correct doses and further details as mentioned in the standards of the protocol.We also hope to ensure that in our area, prn psychotropic medication used for agitation and behavioural disturbance is used safely, appropriately and consistently by staff teams. This would be in accordance with the guidelines.