More case reports in child psychiatry needed

For some people, case reports and case series are at the cornerstone of medical progress as they permit the discovery of new diseases, unexpected effects of treatments, recognition of rare manifestations of disease, and have a key role in medical education. Although regarded at the bottom of the evidence-based hierarchy, case reports hold advantages over the gold standard of randomised clinical trials. These, although having the power to provide a statistical answer for well-defined clinical questions, are expensive, can take years to conduct and may encounter ethical problems. Moreover, it may be impossible to collect adequate numbers in some rare medical conditions. Case reports can be published quickly by busy clinicians with an invaluable experience working in a naturalistic environment and can offer detailed information on the variables of a particular patient that do not always have space in a clinical trial. ¹

Authors like Jeniceck ² highlight how the concept of evidence-based medicine is intrinsically linked with case reporting as they are often the ‘first line of evidence’ and an active example of deductive reasoning. Let us not forget that the history of modern psychiatry is full of examples – Emil Kraepelin, or Leo Kanner as a representative of child psychiatry – where the detailed study of individual or multiple cases led to the identification and grouping of patterns of symptoms from which the diagnostic categories widely used nowadays were derived.

In my career I have published several cases reports. Each of them has been a reminder of the fact that in our practice, clinicians encounter challenging cases with unusual presentations where there may be limited evidence-based knowledge with which to make management decisions. And it is in these situations where careful consideration, assessment of the clinical picture, history of the symptoms, and discussion and consultation with colleagues and relevant professionals have proved a helpful pragmatic approach in making decisions on how to manage a complex presentation. ³

Child psychiatry is a specialty that represents extremely well the complexity of cases with multiple biological and social interactions. My current job at the National Deaf CAMHS is even more representative. One of the challenges when working with deaf children with mental health problems is to produce research applicable to this population, mostly because there is not a consistent profile of a ‘deaf child’: varied causality, including genetic conditions, different levels of deafness, additional special needs, etc. This context makes the need for sharing clinicians' experience through case reports even more relevant.

The guidance on supporting information for appraisal and revalidation issued by the Royal College of Psychiatrists in September 2014 includes a ‘case review or discussion … to demonstrate that you are engaging meaningfully in discussion with your medical and non-medical colleagues in order to maintain and enhance the quality of your professional work.’ ⁴ But other forums, such as-peer reviewed journals, devote less and less space to case reports, including case reports in child psychiatry, which are almost non-existent in high impact factor journals despite the development in recent years of clear guidelines to ensure rigorous reporting. ⁵

Now more than ever, we need case reports to reinvigorate child psychiatry and keep our clinical skills sharp.