Child and Adolescent Psychiatry and Mental Health - Latest Articles

Case Report Of Ganser Syndrome In A 14-year-old Girl: Another Face Of Depressive Disorder ?

Michel Spodenkiewicz — 2012-02-01T00:00:00Z

The Ganser syndrome is rare in children and in adolescents. A case of Ganser syndrome in a 14-year-old girl, with three of the four essential features, is presented. After rapid resolution in two weeks, Ganser symptoms reappear seven months later accompanied, this second time, by previous depressive symptoms. This report raises the possibility of Ganser syndrome as a manifestation of depressive disorder in adolescence.

Adolescent male with anorexia nervosa: a case report from Iraq

Maha Younis — 2012-01-26T00:00:00Z

This is the first reported case of an adolescent male with anorexia nervosa in Iraq. This disorder is believed to be rare in males across cultures and uncommon for both genders in Arab countries. The patient met the DSM-IV diagnostic criteria for anorexia nervosa. He was hospitalized and received medical and psychiatric treatment at local facilities as discussed below and responded well to treatment.

Lead exposure and the 2010 achievement test scores of children in New York counties

Jillian Strayhorn — 2012-01-23T00:00:00Z

Background: Lead is toxic to cognitive and behavioral functioning in children even at levels well below those producing physical symptoms. Continuing efforts in the U.S. since about the 1970s to reduce lead exposure in children have dramatically reduced the incidence of elevated blood lead levels (with elevated levels defined by the current U.S. Centers for Disease Control threshold of 10 micrograms/deciliter). The current study examines how much lead toxicity continues to impair the academic achievement of children of New York State, using 2010 test data. Methods: This study relies on three sets of data published for the 57 New York counties outside New York City: school achievement data from the New York State Department of Education, data on incidence of elevated blood lead levels from the New York State Department of Health, and data on income from the U.S. Census Bureau. We studied third grade and eighth grade test scores in English Language Arts and mathematics. Using the county as the unit of analysis, we computed bivariate correlations and regression coefficients, with percent of children achieving at the lowest reported level as the dependent variable and the percent of preschoolers in the county with elevated blood lead levels as the independent variable. Then we repeated those analyses using partial correlations to control for possible confounding effects of family income, and using multiple regressions with income included. Results: The bivariate correlations between incidence of elevated lead and number of children in the lowest achievement group ranged between 0.38 and 0.47. The partial correlations ranged from 0.29 to 0.40. The regression coefficients, both bivariate and partial (both estimating the increase in percent of children in the lowest achievement group for every percent increase in the children with elevated blood lead levels), ranged from 0.52 to 1.31. All regression coefficients, when rounded to the nearest integer, were approximately 1. Thus, when the percent of children showing elevated lead increases by one percent, the percent of children in the lowest achievement group, according to the regression equations generated, also increases by about one percent. All associations were significant at the 0.05 level. Conclusion: Despite public health advances, and despite the imprecision of measures, an association between the incidence of elevated blood lead and achievement in New York counties is still apparent, not attributable to confounding by income. Efforts to reduce lead exposure should persist with vigor.

A two-session psychological intervention for siblings of pediatric cancer patients: a randomized controlled pilot trial

Alice Prchal — 2012-01-11T00:00:00Z

Background: Since siblings of pediatric cancer patients are at risk for emotional, behavioral, and social problems, there is considerable interest in development of early psychological interventions. This paper aimed at evaluating the effectiveness of a two-session psychological intervention for siblings of newly diagnosed pediatric cancer patients. Methods: Thirty siblings age 6-17 years were randomly assigned to an intervention group or an active control group with standard psycho-oncological care. The manualized intervention provided to siblings in the first 2 months after the cancer diagnosis of the ill child included medical information, promotion of coping skills, and a psychoeducational booklet for parents. At 4 to 6 weeks, 4 months, and 7 months after the diagnosis, siblings and their parents completed measures (from standardized instruments) of social support, quality of life, medical knowledge, posttraumatic stress symptoms, and anxiety. Results: At follow-up siblings in the intervention group showed better psychological well-being, had better medical knowledge, and reported receiving social support from more people. However, the intervention had no effects on posttraumatic stress symptoms and anxiety. Conclusions: The results of this pilot trial suggest that a two-session sibling intervention can improve siblings' adjustment, particularly psychological well-being, in the early stage after a cancer diagnosis.

A systematic review of the safety information contained within the Summaries of Product Characteristics of medications licensed in the United Kingdom for Attention Deficit Hyperactivity Disorder. How does the safety prescribing advice compare with National Guidance?

Nicola Savill — 2012-01-10T00:00:00Z

Background: The safety of paediatric medications is paramount and contraindications provide clear pragmatic advice. Further advice may be accessed through Summaries of Product Characteristics (SPCs) and relevant national guidelines. The SPC can be considered the ultimate independent guideline and is regularly updated. In 2008, the authors undertook a systematic review of the SPC contraindications of medications licensed in the United Kingdom (UK) for the treatment of Attention Deficit Hyperactivity Disorder (ADHD). At that time, there were fewer contraindications reported in the SPC for atomoxetine than methylphenidate and the specific contraindications varied considerably amongst methylphenidate formulations. In 2009, the European Medicines Agency (EMA) mandated harmonisation of methylphenidate SPCs. Between September and November 2011, there were three changes to the atomoxetine SPC that resulted in revised prescribing information. In addition, Clinical Guidance has also been produced by the National Institute for Health and Clinical Excellence (NICE) (2008), the Scottish Intercollegiate Guidelines Network (SIGN) (2009) and the British National Formulary for Children (BNFC). Methods: An updated systematic review of the Contraindications sections of the SPCs of all medications currently licensed for treatment of ADHD in the UK was undertaken and independent statements regarding contraindications and relevant warnings and precautions were then compared with UK national guidance with the aim of assessing any disparity and potential areas of confusion for prescribers. Results: As of November 2011, there were seven medications available in the UK for the treatment of ADHD. There are 15 contraindications for most formulations of methylphenidate, 14 for dexamfetamine and 5 for atomoxetine. Significant differences exist between the SPCs and national guidance part due to the ongoing reactive process of amending the former as new information becomes known. In addition, recommendations are made outside UK SPC licensed indications and a significant contraindication for methylphenidate (suicidal behaviours) is missing from both the NICE and SIGN guidelines. Particular disparity exists relating to monitoring for suicidal and psychiatric side effects. The BNFC has not yet been updated in line with the European Union (EU) Directive on methylphenidate; it does not include any contraindications for atomoxetine but describes contraindications for methylphenidate that are no longer in the SPC. Conclusions: Clinicians seeking prescribing advice from critical independent sources of data, such as SPCs and national guidelines, may be confused by the disparity that exists. There are major differences between guidelines and SPCs and neither should be referred to in isolation. The SPC represents the most relevant source of safety data to aid prescribing of medications for ADHD as they present the most current safety data in line with increased exposure. National guidelines may need more regular updates.

Differences between children and adolescents who commit suicide and their peers: A psychological autopsy of suicide victims compared to accident victims and a community sample.

Anne Freuchen — 2012-01-04T00:00:00Z

Background: The purpose of this study was to gain knowledge about the circumstances related to suicide among children and adolescents 15 years and younger. Methods: We conducted a psychological autopsy, collecting information from parents, hospital records and police reports on persons below the age of 16 who had committed suicide in Norway during a 12-year period (1993-2004) (n=41). Those who committed suicide were compared with children and adolescents who were killed in accidents in the same time period (n=43) and with a community sample. Results: Among the suicides 25% met the criteria for a psychiatric diagnosis and 30% had depressive symptoms at the time of death. Furthermore, 60% of the parents of suicide victims reported the child had some kind of stressful conflict prior to death, whereas only 12% of the parents of the accident victims reported such conflicts. Conclusion: One in four of the suicide victims fulfilled the criteria for a psychiatric diagnosis.The level of sub-threshold depression and of stressful conflict experienced by youths who comitted suicide did not appear to differ substantially from that of their peers, and therefore did not raise sufficient concern for referral to professional help.

Patient characteristics, comorbidities, and medication use for children with ADHD with and without a co-occurring reading disorder: A retrospective cohort study

Peter Classi — 2011-12-06T00:00:00Z

Background: Children and adolescents with attention-deficit/hyperactivity disorder (ADHD) often have a co-occurring reading disorder (RD). The purpose of this research was to assess differences between children with ADHD without RD (ADHD-only) and those with ADHD and co-occurring RD (ADHD+RD). Methods: Using data from the U.S. Thomson Reuter Marketscan® Databases for the years 2005 through 2007, this analysis compared the medical records--including patient demographics, comorbidities, and medication use--of children (age < 18) with ADHD-only to those with ADHD+RD. Results: Patients with ADHD+RD were significantly younger, more likely to have received a procedure code associated with formal psychological or non-psychological testing, and more likely to have been diagnosed with comorbid bipolar disorder, conduct disorder, or depression. They were no more likely to have received an antidepressant, anti-manic (bipolar), or antipsychotic, and were significantly less likely to have received a prescription for a stimulant medication. Conclusions: Relying on a claims database, there appear to be differences in the patient characteristics, comorbidities, and medication use when comparing children with ADHD-only to those with ADHD+RD.

Emotional problems in preadolescents in Norway: The role of gender, ethnic minority status, and home- and school-related hassles

Daniele Alves — 2011-11-17T00:00:00Z

Background: "The gender gap" refers to a lifelong higher rate of emotional problems in girls, as compared to boys, that appears during adolescence. The gender gap is a well-replicated finding among older adolescents and is assumed to be a cross-cultural phenomenon. However, these cross-cultural studies have not investigated the gender gap in ethnic minorities but sampled ethnic majority adolescents in different countries. Some studies that investigated the gender gap across ethnic groups indirectly (by presenting emotional problem scores stratified by gender and ethnic group) indicate that the gender gap is less prominent or even absent among minorities. The aims of this study were to assess whether the gender gap is found in both majority and minority preadolescents, and to investigate whether a possible (gender and ethnic) group difference can be accounted for by differences in home or school hassles. Methods: Participants were 902 preadolescent students (aged 10 to 12) from two cities in Norway. We collected self-report measures of emotional problems and home and school hassles. Using mediated moderation analysis we tested whether the interaction effect between gender and ethnic minority background on emotional problems was mediated by home or school hassles. Results: The gender gap in emotional problems was restricted to ethnic majority preadolescents. School hassles but not home hassles accounted in part for this effect. Conclusions: The absence of the gender gap among minority as opposed to majority preadolescents may indicate that social circumstances may postpone or hamper the emergence and magnitude of the gender gap in ethnic minority preadolescents. In this study, school hassles partly accounted for the combined gender and ethnic group differences on emotional problems. This indicates that school hassles may play a role in the higher levels of emotional problems in preadolescent minority boys and consequently the absence of a gender gap found in our minority sample.

The Treatment of Severe Child Aggression (TOSCA) Study: Design Challenges

Cristan Farmer — 2011-11-10T00:00:00Z

Background: Polypharmacy (the concurrent use of more than one psychoactive drug) and other combination interventions are increasingly common for treatment of severe psychiatric problems only partly responsive to monotherapy. This practice and research on it raise scientific, clinical, and ethical issues such as additive side effects, interactions, threshold for adding second drug, appropriate target measures, and (for studies) timing of randomization. One challenging area for treatment is severe child aggression. Commonly-used medications, often in combination, include psychostimulants, antipsychotics, mood stabilizers, and alpha-2 agonists, which vary considerably in terms of perceived safety and efficacy. Results: In designing our NIMH-funded trial of polypharmacy, we focused attention on the added benefit of a second drug (risperidone) to the effect of the first (stimulant). We selected these two drugs because their associated adverse events might neutralize each other (e.g., sleep delay and appetite decrease from stimulant versus sedation and appetite increase from antipsychotic). Moreover, there was considerable evidence of efficacy for each drug individually for the management of ADHD and child aggression. The study sample comprised children (ages 6-12 years) with both diagnosed ADHD and disruptive behavior disorder (oppositional-defiant or conduct disorder) accompanied by severe physical aggression. In a staged sequence, the medication with the least problematic adverse effects (stimulant) was openly titrated in 3 weeks to optimal effect. Participants whose behavioral symptoms were not normalized received additional double-blind medication, either risperidone or placebo, by random assignment. Thus children whose behavioral symptoms were normalized with stimulant medication were not exposed to an antipsychotic. All families participated in an empirically-supported parent training program for disruptive behavior, so that the actual comparison was stimulant+parent training versus stimulant+antipsychotic+parent training. Conclusions: We hope that the resolutions of the challenges presented here will be useful to other investigators and facilitate much-needed research on child psychiatric polypharmacy.Trial RegistrationClinicalTrials.gov NCT00796302

Efficacy of lisdexamfetamine dimesylate in children with attention-deficit/hyperactivity disorder previously treated with methylphenidate: a post hoc analysis

Rakesh Jain — 2011-11-04T00:00:00Z

Background: Attention-deficit/hyperactivity disorder (ADHD) is a common neurobehavioral psychiatric disorder that afflicts children, with a reported prevalence of 2.4% to 19.8% worldwide. Stimulants (methylphenidate [MPH] and amphetamine) are considered first-line ADHD pharmacotherapy. MPH is a catecholamine reuptake inhibitor, whereas amphetamines have additional presynaptic activity. Although MPH and amphetamine can effectively manage ADHD symptoms in most pediatric patients, many still fail to respond optimally to either. After administration, the prodrug stimulant lisdexamfetamine dimesylate (LDX) is converted to l-lysine and therapeutically active d-amphetamine in the blood. The objective of this study was to evaluate the clinical efficacy of LDX in children with ADHD who remained symptomatic (ie, nonremitters; ADHD Rating Scale IV [ADHD-RS-IV] total score > 18) on MPH therapy prior to enrollment in a 4-week placebo-controlled LDX trial, compared with the overall population. Methods: In this post hoc analysis of data from a multicenter, randomized, double-blind, forced-dose titration study, we evaluated the clinical efficacy of LDX in children aged 6-12 years with and without prior MPH treatment at screening. ADHD symptoms were assessed using the ADHD-RS-IV scale, Conners' Parent Rating Scale-Revised short form (CPRS-R), and Clinical Global Impressions-Improvement scale, at screening, baseline, and endpoint. ADHD-RS-IV total and CPRS-R ADHD Index scores were summarized as mean (SD). Clinical response for the subgroup analysis was defined as a ≥ 30% reduction from baseline in ADHD-RS-IV score and a CGI-I score of 1 or 2. Dunnett test was used to compare change from baseline in all groups. Number needed to treat to achieve one clinical responder or one symptomatic remitter was calculated as the reciprocal of the difference in their proportions on active treatment and placebo at endpoint. Results: Of 290 randomized participants enrolled, 28 received MPH therapy at screening, of which 26 remained symptomatic (ADHD-RS-IV > 18). ADHD-RS-IV total scores, changes from baseline, clinical responsiveness, and rates of symptomatic remission in this subgroup were comparable to the overall population. The safety and tolerability profiles for LDX were comparable to other stimulants currently available. Conclusion: In this analysis, children with significant clinical ADHD symptoms despite MPH treatment improved during treatment with LDX and experienced similar improvements in their symptoms as the overall study population.Trial RegistrationClinicalTrials.gov: NCT00556296