Commentary:The evidence base regarding the long-term effects of childhood mental disorder treatments needs to be strengthened – reply to Dekkers et al. (2023)

In their reply to our editorial (Journal of Child Psychology and Psychiatry, 2023, 64, 464), Dekkers et al. (Journal of Child Psychology and Psychiatry, 2023, 64, 470) argue that treatment is the best choice for children with mental disorders because there is ‘sound evidence’ that interventions are effective, also in the long term. We agree that there is sound evidence for treatment effectiveness in the short-term and there is some evidence for longer-term effects of certain specific treatments, such as behavioral parent training in children with behavioral disorders, as acknowledged in our editorial. However, we strongly disagree that there is sound evidence for long-term effectiveness.</p

The advantages of an ADHD classification from the perspective of teachers

In Western countries, the number of ADHD diagnoses and medical treatments of children has risen spectacularly over the last decennia, as has the amount of criticism about this trend. Various studies have shown that children receiving an ADHD classification often follow from initial signals that were raised in a school context. Hence, it becomes important to investigate precisely what advantages attach to ADHD classification in educational practice. In this qualitative study, 30 teachers were interviewed about their experiences and views of ADHD. The results suggest that a small number of interviewees sees no advantages to ADHD classification: the classification does not practically help them as teachers, they are familiar with the drawbacks of ADHD classification, and they take issue with the idea of labelling children. The greater number of interviewees, however, suggest ambivalence about ADHD classification: they are aware of its drawbacks while experiencing mainly advantages. According to the interviewees, ADHD classification explains undesirable behaviours and disappointing academic achievement. Classification thereby removes blame from pupils, parents and teachers, and so can be a starting point for productive agreement and collaboration. We will discuss the implications of these findings in the light of the concept of reification, child-centred problematisation and the development of more inclusive education

Teachers' perceptions of behavioral problems in Dutch primary education pupils:The role of relative age

A growing number of studies suggest that relatively young behavior of pupils gives them a much greater likelihood of being diagnosed with a disorder such as ADHD. This 'relative age effect' has also been demonstrated for special educational needs, learning difficulties, being bullied, and so on. The current study investigated the relationship between relative age of pupils in primary education and teachers' perception of their behavior. The study sample included 1973 pupils, aged between 6 and 12. Six linear mixed models were carried out with birth day in a year as predictor variable and 'total problem score', 'problems with hyperactivity', 'behavioral problems', 'emotional problems', 'problems with peers' and 'pro-social behavior' as dependent variables. Random intercepts were added for school and teacher level. Cluster-mean centering disaggregated between-school effects and within-school effects. We found no associations between relative age of pupils and teacher perceptions of their behavior. Several explanations are postulated to account for these findings which contradict prior studies on relative age effects

Do troublesome pupils impact teacher perception of the behaviour of their classmates?

The widely supported wish for more inclusive education places ever greater expectations on teachers’ abilities to teach all children, including those with special needs and challenging behaviours. The present study aimed at the question whether teachers judge pupil behaviour more negatively if there are more children with difficult behaviour in class. The teachers of 184 classes in 31 regular primary schools were asked to complete the Strength and Difficulties Questionnaire (SDQ-L) for 3649 pupils. Six linear mixed models were carried out with as independent variable the number of pupils that teachers perceived to have ‘abnormal behaviour’, and the class mean without these pupils as the dependent variable. For all SDQ-L subscales – emotional problems, behavioural problems, problems with hyperactivity, problems with peers, poor prosocial behaviour and total problems – the number of pupils perceived as problematic was associated with less favourable teacher perceptions of the rest of the class. The results of this study are a plea for a contextual perspective on pupil behaviour in class, both where teachers are asked to report on individual pupils, as well as where interventions are done on emotional and behavioural problems in class

The relative impact of school‐wide positive behavior support on teachers’ perceptions of student behavior across schools, teachers, and students

School‐wide positive behavior support (SWPBS) is a systemic approach for implementing a proactive schoolwide discipline and for improving students’ academic and behavioral outcomes by targeting the school’s organizational and social culture. With a multilevel approach, the present study evaluates the relative effectiveness of SWPBS on teachers’ perceptions of the student behavior (N = 3,295) across schools, teachers, and children using a multilevel approach. We assessed teacher perception of student problem behavior five times during a 3‐year implementation of SWPBS in 23 Dutch schools. Multilevel analyses not only revealed a small increase in perceived prosocial behavior and a small decrease in problems with peers, but also different effects across children, teachers, and schools. Effects were stronger for girls and for students with higher severity of perceived problems at baseline. At teachers’ level, higher mean baseline severity of perceived problems was associated with the reduced impact of SWPBS on perceived emotional problems and problems with peers. At the school level, effects were stronger for regular schools as compared with special needs schools

Pharmacological basis and clinical evidence of dabigatran therapy

Dabigatran is an emerging oral anticoagulant which is a direct inhibitor of thrombin activity. It has been approved in the European Union and the United States of America for the prevention of thrombosis after major orthopedic surgery. It has also been approved by the American Food and Drug Administration and the European Medicines Agency for the prevention of stroke in chronic atrial fibrillation. Dabigatran provides a stable anticoagulation effect without any need to perform periodical laboratory controls. Of note, there is a growing amount of clinical evidence which shows its safety and efficacy. For these reasons, dabigatran may suppose a revolution in oral anticoagulation. However, two important limitations remain. First, it is contraindicated in patients with end-stage renal disease. Second, there is no evidence of the prevention of thrombosis in mechanical heart valves

Oral Thromboprophylaxis Following Total Hip or Knee Replacement: Review and Multicentre Experience with Dabigatran Etexilate

The risk of venous thromboembolism (VTE) in patients undergoing total knee or hip replacement surgery is high. As a result, thromboprophylaxis is highly recommended. While current thromboprophylactic agents, such as low molecular weight heparins (LMWH) and vitamin K antagonists, are safe and effective their use can be problematic. Therefore, there is a need for alternative anticoagulants that are as safe and effective as conventional agents, but are more convenient and easier to use. Dabigatran etexilate, a direct thrombin inhibitor, is one such anticoagulant. For VTE prevention following major orthopaedic surgery, dabigatran etexilate shows similar efficacy and safety to the LMWH enoxaparin, and is approved for use in more than 75 countries, including Europe and Canada. Here, we summarize and discuss the experiences of four German clinics that have recently introduced dabigatran etexilate into clinical practice. Overall, dabigatran etexilate was well received by patients, surgeons and nurses, and compared favourably with enoxaparin. Staff appreciated the oral, single-dose administration of dabigatran etexilate. Patient satisfaction was high, especially in those individuals who had previously used LMWHs. In this review, we also address a number of questions that were asked by patients or staff; this will be of relevance to orthopaedic surgeons and nurses. We conclude that, in these four German clinics, dabigatran etexilate offered an effective oral alternative to existing thromboprophylactic agents in patients undergoing major orthopaedic surgery

Anticoagulants and the Propagation Phase of Thrombin Generation

The view that clot time-based assays do not provide a sufficient assessment of an individual's hemostatic competence, especially in the context of anticoagulant therapy, has provoked a search for new metrics, with significant focus directed at techniques that define the propagation phase of thrombin generation. Here we use our deterministic mathematical model of tissue-factor initiated thrombin generation in combination with reconstructions using purified protein components to characterize how the interplay between anticoagulant mechanisms and variable composition of the coagulation proteome result in differential regulation of the propagation phase of thrombin generation. Thrombin parameters were extracted from computationally derived thrombin generation profiles generated using coagulation proteome factor data from warfarin-treated individuals (N = 54) and matching groups of control individuals (N = 37). A computational clot time prolongation value (cINR) was devised that correlated with their actual International Normalized Ratio (INR) values, with differences between individual INR and cINR values shown to derive from the insensitivity of the INR to tissue factor pathway inhibitor (TFPI). The analysis suggests that normal range variation in TFPI levels could be an important contributor to the failure of the INR to adequately reflect the anticoagulated state in some individuals. Warfarin-induced changes in thrombin propagation phase parameters were then compared to those induced by unfractionated heparin, fondaparinux, rivaroxaban, and a reversible thrombin inhibitor. Anticoagulants were assessed at concentrations yielding equivalent cINR values, with each anticoagulant evaluated using 32 unique coagulation proteome compositions. The analyses showed that no anticoagulant recapitulated all features of warfarin propagation phase dynamics; differences in propagation phase effects suggest that anticoagulants that selectively target fXa or thrombin may provoke fewer bleeding episodes. More generally, the study shows that computational modeling of the response of core elements of the coagulation proteome to a physiologically relevant tissue factor stimulus may improve the monitoring of a broad range of anticoagulants