The European road to evidence-based child and adolescent psychiatry

Ruud Minderaa: a careful career

Ruud Minderaa was amongst the founding fathers of contemporary child and adolescent psychiatry. He was devoted to ESCAP for such a long time that one would almost forget his earlier spadework for youth mental health.

Ruud Minderaa, president of ESCAPBefore his appointment as a professor and chairman of the board at the University Medical Centre Groningen, Netherlands (1987), Minderaa spent years as a researcher at the Yale Child Study Center (New Haven, Connecticut, USA) where he helped to set the agenda of modern youth psychiatry with more than 150 peer-reviewed publications. His scientific work on autism stood out most and has influenced many psychiatrists in the eighties and nineties. Considering that ‘difficult children’ in those days would usually meet punishment for their autistic behaviour or – if they were lucky – other ineffective interventions, and parents were blamed for the disorder and sentenced to a lifetime of muddling along without any perspective, Minderaa’s insights marked a true turn-around when introduced in Europe. They caused a halt to the accusation of the children and their parents and opened the door for more effective, behavioural therapies. Meanwhile he also contributed to a better knowledge of other disorders such as Gilles de la Tourette and ADHD, focusing on the evaluation of treatment both from a psychotherapeutical and a pharmacological perspective and the overlap and relationship between ADHD and autism spectrum disorders. Even before his Yale years, when methylphenidate was not often used, Minderaa was one of the first to discuss the possibilities of psychopharmaca for young ADHD patients, like clonidine and other noradrenergic compounds.

Visual rooting reflex
The role of biological and genetic factors in the development of autism spectrum disorder was quite a novelty for European psychiatry in the eighties. One of the remarkable studies that Minderaa conducted with professor George Anderson at Yale’s, concerned primitive reflexes and the influence of certain neurotransmitters (serotonin, dopamine, norepinephrine) in children with autism. “Quite soon we came to the conclusion that environmental influences were in fact overrated”, says professor Anderson. “And recent studies keep confirming that vey early genetic differences – for example in monozygotic twins – may develop without any environmental affect.”
Minderaa surprised European psychiatry with his thesis on ‘primitive snout and visual rooting reflexes’ in children with autism (1985) – another study that has been confirmed by recent research at the Groningen and Yale Universities.
Minderaa is known for his neurochemical studies, and their findings on increased stress responsiveness in children with autism. Anderson and Minderaa researched hyperserotonemia and autism, melatonin values in adolescents with autism and the relationships between increased serotonin levels and behavioural aspects.

 The strategic years
Back in Groningen, Ruud Minderaa took up a political mission: he steadily started revising the reputation of child and adolescent psychiatry. On the patients’ side he fought the stigma of medication in youth psychiatry – a taboo subject, evidence or not – and on the organizational side he was one of the first to turn child psychiatry from an inpatient operation into an outpatient care system. Minderaa strongly opposed against hospitalization – certainly for the youngest – and became a respected advocate of ‘ambulant care’. At his own institution for youth health care – Accare, Groningen – he reduced the number of beds by fifty per cent. 

Evidence-based practice
Ruud Minderaa strongly believed in the improvement of child and adolescent psychiatry by increasing an evidence-based way of working. In spite of persistent opposition by practitioners who kept preferring their own particular therapeutic manners, Accare positioned itself in the forefront of evidence-based practice. Around the year 2000 Minderaa laid the groundwork for a national knowledge centre for child and adolescent psychiatry. With very limited government funding he founded the Dutch Knowledge Centre for Child and Adolescent Psychiatry, bringing together seven (now twenty) funding institutions that managed to turn his Knowledge Centre into a big success. More than eighty per cent of the practitioners in the Netherlands’ youth health care use the Knowledge Centre’s guidance in their day-to-day work. Expert groups from all renowned academic communities, therapists, parents and patients bring their knowledge together to be turned into evidence-based protocols for diagnostics and treatment. This guidance is freely available in the Dutch and English language today. At the IACAPAP conference in Paris (2012) and the ESCAP Congress in Madrid (2015) talks continued to explore the possibility to turn Minderaa’s initiative into a Europe-wide knowledge and guidance base for child psychiatrists and allied professions. 

Implementation
Another one of Minderaa’s strategic aims is linking the expertise from research to practice – not accidently the motto of the 2015 ESCAP Congress. As the president of ESCAP he focused on implementation: “Our priority should not be gathering more knowledge, but making better use of what we already know.”
His managerial successor in Groningen, Jos Rietveld, said at Minderaa’s retirement: “Ruud’s contribution was strategically significant. He kept raising the development of our profession as an issue on each and every board meeting. Vision papers were always thoroughly analysed and amended by Ruud, whilst his reaction to operational matters mostly met his affable agreement.” Rietveld spoke about Minderaa’s “strategic leadership” which expanded from Groningen to the Netherlands and finally to Europe. 

European role
His European activities as an ESCAP board member began in 2002. Apart from important issues like implementation of evidence-based knowledge and the development of European guidelines, ESCAP’s past president Tuula Tamminen emphasizes the importance of the exchange of knowledge between the European and American worlds of child and adolescent psychiatry, which appear to be quite different. “Ruud Minderaa was the appropriate go-between to get the best out of both worlds”, said Tamminen.
Together, Tamminen and Minderaa got ESCAP on a constructive and strategic track again, after a less engaged era. ESCAP increased the congress frequency from four to two years, congress programmes featured top level lecturers, Minderaa introduced dedicated divisions for clinical, academic and policy projects and ESCAP was equipped with a fully fledged on line platform for the exchange of state of the art youth psychiatry knowledge, insights and discussion. Minderaa re-established the connection with European Child + Adolescent Psychiatry (ECAP) its scientific journal, now to be distinguished as the official ESCAP journal
Ruud Minderaa is stepping down as president of ESCAP in June 2015, but he intends to stay closely involved for the next two years as ESCAP’s past president. He was the first to support the initiative of Jan Buitelaar – Minderaa’s successor as chair of the Dutch Knowledge Centre – to set the agenda for European evidence-based guidance for youth psychiatry diagnostics and treatment. Ruud Minderaa provided the foundation of uniform clinical guidelines that may well merge with other European groundwork (NICE, AWMF and other national initiatives) to become the strongest basis ever for a European collaboration in youth psychiatry with proven effectiveness.
Ruud Minderaa stepped down as past president, September 2017.

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