LETTERS TO THE EDITOR Outcome of Inpatient Treatment
Taking the Boards
To the Editor:
To the Editor:
Pfeiffer and Strzelecki (1990) provide a comprehensive and me ticulous review of inpat ient treatment outcome studies. Their points are well made, and we, of course, apprecia te their citing our review and were interested to note their findings generally to be in agreement. We would like to respo nd to a coup le of issues. A maj or trust of this presentation was ' ' to deve lop and apply a more precise and conservative approac h to integrati ng findings . . . by em ploying a statistical procedure to pool the results of previous researc h" (p. 847). Although the authors have clea rly do ne that, we believe they would have done well to have noted for the reade r the necessary ca utio n we know the authors maintain when studying these findings. If the original data are collected without using reliab le or valid measures, if the samples vary widel y and include all ages of youth, if follow -up time frames vary from 0 to 2 mo nths to I I years , if the sources of outcome measurement vary from IQ tests and interview s to questionnaires and record revie ws, then one remai ns careful in entrusti ng too much confidence even in a metanalysis of this kind of poole d da ta. Th e authors acknowledge that they were " forced to develop an alterna tive meth od for syn thesizing the results" (p . 848) . Th e statistical approac h employed appea rs straightforward, clea r, and therefore appealing . It stands "on the face of it " for what it is, and it is certainly a reasoned approac h. However , the authors do not cite a refe rence or provide an ex pla nation of the mathem atical valid ity of their equation for determ ining a weighted pred ictive value (WP Y) . One illustration might be helpful in clarifying the potent ial for the findings of any such analysis to be too confidently accepted. The authors omit studies incl uding youth suffer ing mental reta rdation and severe developm ent al delays . Th en , applying the ir WPY analysis, they conclude that IQ dem onstrated a modestly strong positive relationship to postdischarge ada ptation. Clearly, the interactions of this dimension are complex . Is there a baseline IQ below which there is a significan t negative correlation to later postd ischarge coping? Does IQ affect prognosis more in some disorders than others? Th e calcula tion of WPYs is o nly modestly helpful, is probably more interesting than ultimately meanin gful in term s of validity, and has the potent ial of misleading us into a false sense of confidence about these findings . Pfeiffer and Str zelecki ( 1990) have done an exce llen t job of bringing us up-to-date with the current sta te of knowledge from inpatient treatment assessment follo w-up studies . But let 's not forget the greater efforts requi red by child psychi atrists in designing and implemen ting prospective treatment assess me nt proje cts . More sophisticated statistical analyses of our current data base will not provide the needed information. We encourage child psychiatrists to devote increasi ng energy, money , and manpo wer to designing and completing methodo logica lly sound projects-a task that has not always been well supported by training institutions, funding source s, or me ntors .
Having recently passed the oral Child and Adole scent Psychiatry Boards after two previous unsuccessful atte mpts in 1985 and 1989 and after almost 20 years of private practice , I now fee l so mew hat qualified to comme nt on how to pass and how not to pass the board s, especi ally the oral part. Being "famili ar" with DSM-lII-R diagnoses is not sufficient. For my third attempt, I mem orized all the ch ild and adolesce nt diagn osti c criteria instead. I also mem orized all significant aspec ts of the Me ntal Stat us Examination as we ll as all sig nificant subjec ts to be cov ered in a diagnostic formulation . Thi s provides ment al " shel v ing" upon which the clinical information to be gathered can be stored and categorized . It helps grea tly to practice board-like intervie ws with other candidates in order to have a feel of what to ex pec t, incl uding time pressu res . In additio n, it is also helpful to have previous ly taken the AACAP review course or a previous board exam . I found the video tape/vignette sect ion the most difficult beca use it was the hardest to prepa re for , and the cases present ed often are difficult patients from chaotic , soc ially deprived famili es, less co mmonly seen in private practice . Th ey also make for a more challe nging and ex tensive different ial diagnosis . It would have been helpful to have been able to purcha se a series of practic e vig nettes and practice video tapes to get a better feel for the format and type of pat ient s that I would face . Even thou gh I took the AACAP annu al rev iew course in 1985 and aga in in 1990, such additional pract ice opport unities would have made my 1990 exper ience easier and less anxiety provoking. Not knowing what to expect is one of the most common causes of debilitating anxiety . Overall , I fee l that taking the ora l boards did force me to sharpen my diagnostic skills , whi ch, I feel , made me a better clinician . I am pleased , however , at not having to take the board s aga in.
Mark 1. Blotcky, M .D . Thomas L. Dimper io , Ph.D . Timberlawn Psychi atric Hospital Dallas, Texas REFERENCE
Pfeiffer , S . I. & Strzel ecki , B. A . (1990), Inpatient psychiatr ic treatment of children and adolescents: a review of outcome studies. J .
Am. Acad. Child Ado/esc. Psychiatry. 29:847-853. J .Am .Acad . Child Adolesc. Psychiatry , 30 :3, May 1991
Dirk E . Huttenbach , M .D . Mar ietta , Georgia
Fenfluramine and Mental Retardation To the Editor: Recentl y, we undertook a doub le-blind, placebo- controlled crossover study comparing the clin ical effects of meth ylphenid ate and fenfluram ine in ment ally retarded ch ildren with sy mpto ms of attention defic it hyper acti vity disorder. Twent y children have been tested thus far, 19 of whom are not autistic. This is unique in that the large maj orit y of previous fenflur amine studies have e mployed only autistic children as subjects (Aman and Kern , 1989 ), and there is on ly one other clinical trial known to us that com pares fcnfl urami ne to another active medication in children (Don nelly e t al., 1989). We would like to take this oppo rtunit y to present some preli minary findi ngs regard ing the side effec ts of fenfl ura mine . We assesse d side effects in our subje cts through parent reports using a modified version of the Dosage and Treatm ent Emerge nt Sympt om s Scale (DOTES) developed for psychoph arm acological trial s by the Nation al Institute s of Mental Health (Guy, 1976; Rapop ort and Conners, 1985 ). Parents, observing reduct ions in motor behav ior, reported on the item, , .Increased motor activity ," where fen fluramine appe ared to be causing significant redu ction s in compar ison with placebo (p = 0 .0 14, Wilcoxon signed ranks tests). Th ese reductions in motor be-
507
Taking the Boards
To the Editor:
To the Editor:
Pfeiffer and Strzelecki (1990) provide a comprehensive and me ticulous review of inpat ient treatment outcome studies. Their points are well made, and we, of course, apprecia te their citing our review and were interested to note their findings generally to be in agreement. We would like to respo nd to a coup le of issues. A maj or trust of this presentation was ' ' to deve lop and apply a more precise and conservative approac h to integrati ng findings . . . by em ploying a statistical procedure to pool the results of previous researc h" (p. 847). Although the authors have clea rly do ne that, we believe they would have done well to have noted for the reade r the necessary ca utio n we know the authors maintain when studying these findings. If the original data are collected without using reliab le or valid measures, if the samples vary widel y and include all ages of youth, if follow -up time frames vary from 0 to 2 mo nths to I I years , if the sources of outcome measurement vary from IQ tests and interview s to questionnaires and record revie ws, then one remai ns careful in entrusti ng too much confidence even in a metanalysis of this kind of poole d da ta. Th e authors acknowledge that they were " forced to develop an alterna tive meth od for syn thesizing the results" (p . 848) . Th e statistical approac h employed appea rs straightforward, clea r, and therefore appealing . It stands "on the face of it " for what it is, and it is certainly a reasoned approac h. However , the authors do not cite a refe rence or provide an ex pla nation of the mathem atical valid ity of their equation for determ ining a weighted pred ictive value (WP Y) . One illustration might be helpful in clarifying the potent ial for the findings of any such analysis to be too confidently accepted. The authors omit studies incl uding youth suffer ing mental reta rdation and severe developm ent al delays . Th en , applying the ir WPY analysis, they conclude that IQ dem onstrated a modestly strong positive relationship to postdischarge ada ptation. Clearly, the interactions of this dimension are complex . Is there a baseline IQ below which there is a significan t negative correlation to later postd ischarge coping? Does IQ affect prognosis more in some disorders than others? Th e calcula tion of WPYs is o nly modestly helpful, is probably more interesting than ultimately meanin gful in term s of validity, and has the potent ial of misleading us into a false sense of confidence about these findings . Pfeiffer and Str zelecki ( 1990) have done an exce llen t job of bringing us up-to-date with the current sta te of knowledge from inpatient treatment assessment follo w-up studies . But let 's not forget the greater efforts requi red by child psychi atrists in designing and implemen ting prospective treatment assess me nt proje cts . More sophisticated statistical analyses of our current data base will not provide the needed information. We encourage child psychiatrists to devote increasi ng energy, money , and manpo wer to designing and completing methodo logica lly sound projects-a task that has not always been well supported by training institutions, funding source s, or me ntors .
Having recently passed the oral Child and Adole scent Psychiatry Boards after two previous unsuccessful atte mpts in 1985 and 1989 and after almost 20 years of private practice , I now fee l so mew hat qualified to comme nt on how to pass and how not to pass the board s, especi ally the oral part. Being "famili ar" with DSM-lII-R diagnoses is not sufficient. For my third attempt, I mem orized all the ch ild and adolesce nt diagn osti c criteria instead. I also mem orized all significant aspec ts of the Me ntal Stat us Examination as we ll as all sig nificant subjec ts to be cov ered in a diagnostic formulation . Thi s provides ment al " shel v ing" upon which the clinical information to be gathered can be stored and categorized . It helps grea tly to practice board-like intervie ws with other candidates in order to have a feel of what to ex pec t, incl uding time pressu res . In additio n, it is also helpful to have previous ly taken the AACAP review course or a previous board exam . I found the video tape/vignette sect ion the most difficult beca use it was the hardest to prepa re for , and the cases present ed often are difficult patients from chaotic , soc ially deprived famili es, less co mmonly seen in private practice . Th ey also make for a more challe nging and ex tensive different ial diagnosis . It would have been helpful to have been able to purcha se a series of practic e vig nettes and practice video tapes to get a better feel for the format and type of pat ient s that I would face . Even thou gh I took the AACAP annu al rev iew course in 1985 and aga in in 1990, such additional pract ice opport unities would have made my 1990 exper ience easier and less anxiety provoking. Not knowing what to expect is one of the most common causes of debilitating anxiety . Overall , I fee l that taking the ora l boards did force me to sharpen my diagnostic skills , whi ch, I feel , made me a better clinician . I am pleased , however , at not having to take the board s aga in.
Mark 1. Blotcky, M .D . Thomas L. Dimper io , Ph.D . Timberlawn Psychi atric Hospital Dallas, Texas REFERENCE
Pfeiffer , S . I. & Strzel ecki , B. A . (1990), Inpatient psychiatr ic treatment of children and adolescents: a review of outcome studies. J .
Am. Acad. Child Ado/esc. Psychiatry. 29:847-853. J .Am .Acad . Child Adolesc. Psychiatry , 30 :3, May 1991
Dirk E . Huttenbach , M .D . Mar ietta , Georgia
Fenfluramine and Mental Retardation To the Editor: Recentl y, we undertook a doub le-blind, placebo- controlled crossover study comparing the clin ical effects of meth ylphenid ate and fenfluram ine in ment ally retarded ch ildren with sy mpto ms of attention defic it hyper acti vity disorder. Twent y children have been tested thus far, 19 of whom are not autistic. This is unique in that the large maj orit y of previous fenflur amine studies have e mployed only autistic children as subjects (Aman and Kern , 1989 ), and there is on ly one other clinical trial known to us that com pares fcnfl urami ne to another active medication in children (Don nelly e t al., 1989). We would like to take this oppo rtunit y to present some preli minary findi ngs regard ing the side effec ts of fenfl ura mine . We assesse d side effects in our subje cts through parent reports using a modified version of the Dosage and Treatm ent Emerge nt Sympt om s Scale (DOTES) developed for psychoph arm acological trial s by the Nation al Institute s of Mental Health (Guy, 1976; Rapop ort and Conners, 1985 ). Parents, observing reduct ions in motor behav ior, reported on the item, , .Increased motor activity ," where fen fluramine appe ared to be causing significant redu ction s in compar ison with placebo (p = 0 .0 14, Wilcoxon signed ranks tests). Th ese reductions in motor be-
507
