Effect of motivation on academic fluency performance in survivors of pediatric medulloblastoma.

It has been proposed previously that extrinsic motivation may enable survivors of childhood medulloblastoma to significantly improve aspects of neurocognitive performance. In healthy populations, enhanced motivation has been shown to promote academic fluency, a domain likely more relevant to the educational outcomes of pediatric medulloblastoma survivors than academic skill development. The present study investigates the effect of enhanced extrinsic motivation on fluent (i.e., accurate and efficient) academic performance in pediatric medulloblastoma survivors. Participants were 36 children, ages 7-18, who had completed treatment for medulloblastoma. Participants completed a neuropsychological battery that included administration of equivalent tasks on Forms A and B of the Woodcock-Johnson III Tests of Achievement. Half were randomly assigned to an incentive condition prior to the administration of Form B. Provision of a performance-based incentive resulted in statistically significant improvement, but not normalization of function, in performance on measures of academic fluency. No demographic, treatment-related, academic, neuropsychological, or self-perception variables predicted response to incentive. Findings suggest that academic performance of survivors may significantly improve under highly motivating conditions. In addition to implications for educational services, this finding raises the novel possibility that decreased motivation represents an inherent neuropsychological deficit in this population and provides a rationale for further investigation of factors affecting individual differences in motivational processes. Further, by examining effort in a context where effort is not inherently suspect, present findings also significantly contribute to the debate regarding the effects of effort and motivation on neuropsychological performance.

School Scoliosis Screenings: Family Experiences and Potential Anxiety After Orthopaedic Referral.

STUDY DESIGN: Cross-sequential study design that used data from Texas Scottish Rite Hospital for Children (TSRHC). OBJECTIVE: Examine anxiety symptoms and family experiences subsequent to school scoliosis screening (SSS) referrals. SUMMARY OF BACKGROUND DATA: Use of SSS remains controversial. Prior research suggested that SSS programs may result in anxiety for both children and parents. Unfortunately, no study has examined the SSS referral processes and anxiety in families. METHODS: Study consisted of 2 groups-patients/parents from TSRHC evaluated for Adolescent Idiopathic Scoliosis (AIS) (n = 27) and control participants/parents (n = 27) between ages 9 and 17. All participants completed the primary outcome measure (State-Trait Anxiety Inventory) before and after the scoliosis evaluation or controlled wait time. Parents also rated experience and satisfaction with SSS. RESULTS: Compared with the control group, children/parents in patient group experienced significantly elevated levels of state-anxiety at preappointment. Children/parents in the patient group not diagnosed with AIS experienced a significant decline in state-anxiety. Children/parents in the patient group diagnosed with AIS continued to report elevated levels of anxiety. The control group remained consistent, reporting of low levels of anxiety pre to post. More than half (55.5%) of families indicated they received no information from the school about scoliosis. A third of the families who received information indicated it did not adequately address their concerns. Nonetheless, most families reported overall satisfaction with SSS. CONCLUSION: This study suggested that children and parents referred through the SSS program experienced significantly elevated levels of state-anxiety. This supports the subjective concerns of anxiety experiences in families voiced by researchers previously. However, families deemed the costs of the SSS referral process as worth the benefits. Though challengers of SSS programs were accurate in observing anxiety in families, it may not constitute significant burden to eliminate SSS programs altogether. Improvements to the current system may be warranted. LEVEL OF EVIDENCE: 3.

School Competence and Fluent Academic Performance: Informing Assessment of Educational Outcomes in Survivors of Pediatric Medulloblastoma.

Academic difficulties are widely acknowledged but not adequately studied in survivors of pediatric medulloblastoma. Although most survivors require special education services and are significantly less likely than healthy peers to finish high school, measured academic skills are typically average. This study sought to identify potential factors associated with academic difficulties in this population and focused on school competence and fluent academic performance. Thirty-six patients (ages 7-18 years old) were recruited through the Departments of Neurosurgery and Neuro-Oncology at Children's Medical Center Dallas and Cook Children's Medical Center in Fort Worth, TX. Participants completed a neuropsychological screening battery including selected Woodcock-Johnson III Tests of Achievement subtests. Parents completed the Child Behavior Checklist. School competence was significantly correlated with measured academic skills and fluency. Basic academic skill development was broadly average, in contrast to significantly worse fluent academic performance. School competence may have utility as a measure estimating levels of educational success in this population. Additionally, academic difficulties experienced by childhood medulloblastoma survivors may be better captured by measuring deficits in fluent academic performance rather than skills. Identification of these potential factors associated with educational outcomes of pediatric medulloblastoma survivors has significant implications for research, clinical assessment, and academic services/interventions.

Differentiating ADHD from oral language difficulties in children: role of movements and effects of stimulant medication.

BACKGROUND: The current study was designed to test if an objective measure of both attention and movement would differentiate children with Oral Language Disorders (OLD) from those with comorbid Attention Deficit/Hyperactivity Disorder (ADHD) and if stimulant medication improved performance when both disorders were present. METHODS: The sample consisted of thirty-three children with an identified oral language disorder (of which 22 had comorbid ADHD) ages 6 to 13 who were enrolled in a yearlong intensive learning intervention program. Those on a stimulant medication were tested at baseline and again a year later on and off medication. RESULTS: Objective measures that included an infrared motion analysis system which tracked and recorded subtle movements discriminated children with OLD from those with a comorbid ADHD disorder whereas classic attention measures did not. There were better attention scores and fewer movements in children while on-medication. CONCLUSIONS: Use of an objective measurement that includes movement detection improves objective diagnostic differential for OLD and ADHD and provides quantifiable changes in performance related to medication for both OLD and ADHD.

Association of depressive symptoms with hippocampal volume in 1936 adults.

Hippocampal atrophy is reported in major depressive disorder (MDD). However, sample sizes were generally modest, and participant characteristics, including age, differed between studies. This study used a community sample to examine relationships between current depressive symptom severity and hippocampal volume across the adult lifespan. A total of 1936 adults with magnetic resonance images of the brain and Quick Inventory of Depressive Symptomatology Self-Report (QIDS-SR) scores were included. Brain volumes were quantified using the FSL program. Multiple linear regressions were performed using left, right, and total hippocampal volume as criterion variables, and predictor variables of QIDS-SR total, total brain volume, age, gender, education, psychotropic medications, alcohol use, and race/ethnicity. Post hoc analyses were conducted in participants with QIDS-SR scores 11 (moderate or greater depressive symptom severity) and <11, and older and younger adults. In the primary analysis (sample as a whole) QIDS-SR was inversely associated with total hippocampal volume (b=-0.044, p=0.032, (CI-0.019 to -0.001)) but not with left or right hippocampal volume evaluated individually. In participants with QIDS-SR scores of <11, hippocampal volumes were not associated with QIDS-SR scores. In those with QIDS-SR scores 11 total, right, and left hippocampal volumes were modestly, but significantly, associated with QIDS-SR scores. The association between QIDS-SR scores and the hippocampal volume was much stronger in older persons. Findings suggest smaller hippocampal volumes among those with greater reported depressive symptom severity-an association that is strongest in people with at least moderate depressive symptom levels.

An open trial of a metacognitive executive function training for young children with ADHD.

OBJECTIVE: Executive functioning is impaired in children with ADHD and putatively related to the pathogenesis of ADHD. The authors developed an innovative treatment teaching parents to administer a metacognitive executive function training intervention with children, promoting positive interactions during activities designed to improve attention and self-regulation. METHOD: A total of 24 young children with ADHD and their parents participated in an 8-week open trial of the intervention designed to assess feasibility and initial efficacy. RESULTS: The intervention is feasible and accepted by parents as shown by high attendance/adherence, low attrition, and satisfaction ratings. Improvements in executive functions (visual/auditory attention, working memory, and cognitive flexibility) with corresponding improvements in parent ratings of executive functioning were observed. Reduced inattention symptoms were reported. CONCLUSION: Executive functioning training is a promising approach to treating young children with ADHD and holds promise for generalizability because parents are trained to be interventionists and coached to apply the strategies to alternative domains.

Depressed Adolescents Treated with Exercise (DATE): A pilot randomized controlled trial to test feasibility and establish preliminary effect sizes.

The Depressed Adolescents Treated with Exercise (DATE) study evaluated a standardized aerobic exercise protocol to treat nonmedicated adolescents that met DSM-IV-TR criteria for major depressive disorder. From an initial screen of 90 individuals, 30 adolescents aged 12-18 years were randomized to either vigorous exercise (EXER) (>12 kg/kcal/week [KKW]) or a control stretching (STRETCH) activity (< 4 KKW) for 12 weeks. The primary outcome measure was the blinded clinician rating of the Children's Depression Rating Scale - Revised (CDRS-R) to assess depression severity and Actical (KKW) accelerometry 24hr/7days a week to assess energy expenditure and adherence. Follow-up evaluations occurred at weeks 26 and 52. The EXER group averaged 77% adherence and the STRETCH group 81% for meeting weekly target goals for the 12 week intervention based on weekly sessions completed and meeting KKW requirements. There was a significant increase in overall weekly KKW expenditures (p < .001) for both groups with the EXER group doubling the STRETCH group in weekly energy expenditure. Depressive symptoms were significantly reduced from baseline for both groups with the EXER group improving more rapidly than STRETCH after six weeks (p < .016) and nine weeks (p < .001). Both groups continued to improve such that there were no group differences after 12 weeks (p = .07). By week 12, the exercise group had a 100% response rate (86% remission), whereas the stretch group response rate was 67% (50% remission) (p = .02). Both groups had improvements in multiple areas of psychosocial functioning related to school and relationships with parents and peers. Anthropometry reflected decreased waist, hip and thigh measurements (p = .02), more so for females than males (p = .05), but there were no weight changes for either gender. The EXER group sustained 100% remission at week 26 and 52. The STRETCH group had 80% response and 70% remission rates at week 26 and by week 52 only one had not fully responded. The study provides support for the use of exercise as a non-medication intervention for adolescents with major depressive disorders when good adherence and energy expenditure (KKW) are achieved.

Maternal depressive symptoms predict adolescent healthcare utilization and charges in youth with type 1 diabetes (T1D).

OBJECTIVE: To examine whether maternal depressive symptoms predict diabetes-related health care utilization and charges in adolescents with Type 1 diabetes. METHOD: Mothers of adolescents ages 11-18 with Type 1 diabetes completed the Center for Epidemiological Studies Depression Scale at enrollment and at 12-month follow-up. Demographic and disease-related variables, including HbA1c, were also assessed. Health care utilization data and charges for diabetes-related care (i.e., endocrine clinic visits, emergency room visits, and hospitalizations) for the period of 12 and 24 months following enrollment were assessed. RESULTS: Maternal depressive symptoms at enrollment predicted higher utilization/charges at 12- and 24-month follow-up, after controlling for demographic and disease-related variables and adolescent depressive symptoms. High maternal depressive symptoms at baseline were associated with $8,405 additional charges over the next 2 years. Adolescents of mothers with high depressive symptoms were twice as likely to have an emergency room visit and three times as likely to have a hospitalization. CONCLUSION: Maternal depressive symptoms are an independent predictor of health care utilization and charges in adolescents with Type 1 diabetes. Interventions aimed at identifying and treating depressive symptoms in mothers could not only enhance caregiver quality of life but could also be economically advantageous for payers and providers.

Preliminary data suggesting the efficacy of attention training for school-aged children with ADHD.

A pilot randomized clinical trial was conducted to examine the initial efficacy of Pay Attention!, an intervention training sustained, selective, alternating, and divided attention, in children diagnosed with Attention-Deficit/Hyperactivity Disorder (ADHD). After a diagnostic and baseline evaluation, school-aged children with ADHD were randomized to receive 16 bi-weekly sessions of Pay Attention! (n=54) or to a waitlist control group (n=51). Participants completed an outcome evaluation approximately 12 weeks after their baseline evaluation. Results showed significant treatment effects for parent and clinician ratings of ADHD symptoms, child self-report of ability to focus, and parent ratings of executive functioning. Child performance on neuropsychological tests showed significant treatment-related improvement on strategic planning efficiency, but no treatment effects were observed on other neuropsychological outcomes. Treatment effects were also not observed for teacher ratings of ADHD. These data add to a growing body of literature supporting effects of cognitive training on attention and behavior, however, additional research is warranted.

Separate and overlapping relationships of inattention and hyperactivity/impulsivity in children and adolescents with attention-deficit/hyperactivity disorder.

There is debate regarding the dimensional versus categorical nature of attention-deficit/hyperactivity disorder (ADHD). This study utilized confirmatory factor analysis to examine this issue. ADHD symptoms rated on interviews and rating scales from a large sample of individuals (ages 3-17, 74 % male, 75 % Caucasian) with ADHD were examined (n = 242). Four potential factor structures were tested to replicate prior findings in a sample with a wide age range and included only participants who met DSM-IV-TR diagnostic criteria for ADHD. Correlations with executive function measures were performed to further assess the separability and validity of the derived factors. The data support a bifactor model with a general ADHD factor and two specific factors, inattention and hyperactivity/impulsivity. Importantly, the individual factors were also differentially correlated with executive functioning measures. This study adds to a growing literature suggesting both a general component to ADHD, as well as dimensional traits of inattention and hyperactivity/impulsivity, associated with distinct executive functioning profiles. The presence of a general underlying factor contraindicates separating the inattentive and combined subtypes of ADHD into distinct disorders.

Insomnia moderates outcome of serotonin-selective reuptake inhibitor treatment in depressed youth.

OBJECTIVE: Insomnia is evident in the majority of youth with depression, and is associated with poorer outcomes. There are limited data on the impact of insomnia in response to acute treatment, which is particularly relevant with serotonin-selective reuptake inhibitors, given their tendency to worsen sleep architecture. METHODS: Three hundred nine children and adolescents (ages 7-18 years) were randomized to fluoxetine (n=157) or placebo (n=152) for 8-9 weeks (Emslie et al.1997, 2002). Substantial insomnia at baseline was defined as a child's depression rating scale-revised [CDRS-R] sleep item ≥ 4. Outcome measures were CDRS-R, response, and remission. RESULTS: Insomnia was reported in 172/309 (55.7%) youth, and was associated with higher depression severity and greater fatigue, suicidal ideation, physical complaints, and decreased concentration. While response rates were similar in those with or without insomnia overall (51.7% vs. 55.7%), there is a significant difference by age group. Among adolescents, those with insomnia were less likely to respond to fluoxetine (39.2%; 20/51) than those without (65.9%; 27/41; p=0.013), while in children on fluoxetine, those with insomnia were more likely to respond to fluoxetine (69.4%; 25/36) than those without insomnia (41.4%; 12/29; p=0.027). Insomnia did not impact the response to placebo in either age group. Within adolescents, the overall least squares means for CDRS-R total score (across the 8 weeks of treatment) were significantly different between those who had insomnia versus those who did not within the fluoxetine group (43.65 [SE=1.31] vs. 36.58[SE=1.45], F=12.69, df=1, 169, p=0.0005; d=0.82), but not within the placebo group (44.91[SE=1.34] vs. 43.75[SE=1.68], F=0.29, df=1, 179, p=0.591; d=0.15). CONCLUSIONS: While adolescents reporting substantial insomnia were less likely to respond to antidepressant treatment than those without insomnia, children were more responsive to fluoxetine when they had insomnia. Additional intervention targeting sleep disturbance may be warranted in adolescents.

Metaparenting: associations with parenting stress, child-rearing practices, and retention in parents of children at risk for ADHD.

The aim of the study is to investigate metaparenting (effortful, deliberate cognition about parenting) in parents of children at risk for ADHD including predictors, correlates, and intervention outcomes. Parents (n = 68) of children with significant ADHD symptoms (i.e., ≥ 6 inattentive or hyperactive/impulsive symptoms with impairment in ≥ 2 settings, mostly un-medicated) provided ratings of metaparenting, parenting stress and practices, and child ADHD symptoms before and after parent training. Parents were predominantly Caucasian, in their upper thirties, and most had schooling beyond high school. We investigated the relation between metaparenting and baseline predictors, and whether metaparenting predicted (1) parenting behaviors at baseline, (2) attrition, and (3) parenting stress and parent/child behaviors at outcome. More educated mothers, with fewer people living in the home, and higher levels of parenting stress, reported more metaparenting. Parents with lower problem-solving and assessing scores reported more inconsistent parenting, and those with lower problem-solving scores were more likely to drop out of parent training. Higher problem-solving and reflecting scores at baseline were associated with more parental stress. Higher reflecting at baseline predicted child hyperactivity/impulsivity at outcome. Our findings indicate metaparenting is associated with parenting behaviors and decisions to complete parent training. Furthermore, metaparenting appears to be a complex, finely nuanced construct with both positive and negative associations with reports of parenting practices and stress.

Children of depressed mothers 1 year after remission of maternal depression: findings from the STAR*D-Child study.

OBJECTIVE: Maternal major depressive disorder is an established risk factor for child psychopathology. The authors previously reported that 1 year after initiation of treatment for maternal depression, children of mothers whose depression remitted had significantly improved functioning and psychiatric symptoms. This study extends these findings by examining changes in psychiatric symptoms, behavioral problems, and functioning among children of depressed mothers during the first year after the mothers' remission from depression. METHOD: Children were assessed at baseline and at 3-month intervals with the Schedule for Affective Disorders and Schizophrenia for School-Age Children-Present and Lifetime Version, the Child Behavior Checklist, and the Children's Global Assessment Scale for 1 year after their mothers' remission or for 2 years if the mothers did not remit. The authors compared children of early remitters (0-3 months; N=36), late remitters (3-12 months; N=28), and nonremitters (N=16). RESULTS: During the postremission year, children of early-remitting mothers showed significant improvement on all outcomes. Externalizing behavioral problems decreased in children of early- and late-remitting mothers but increased in children of nonremitting mothers. Psychiatric symptoms decreased significantly only in children of mothers who remitted, and functioning improved only in children of early-remitting mothers. CONCLUSIONS: Remission of mothers' depression, regardless of its timing, appears to be related to decreases in problem behaviors and symptoms in their children over the year after remission. The favorable effect of mothers' remission on children's functioning was observed only in children of early-remitting mothers.

A comparison of various methods of measuring antidepressant medication adherence among children and adolescents with major depressive disorder in a 12-week open trial of fluoxetine.

OBJECTIVE: In this study, we examined antidepressant (fluoxetine) medication adherence in children and adolescents with major depressive disorder (MDD). Using electronic monitoring (EM) as the "reference standard," we compared various methods of measuring antidepressant medication adherence (including EM, pill counts, and medication diaries) among children and adolescents with MDD and examined the relationship between EM medication adherence and depression severity across time. We then suggested recommendations for clinical researchers and practicing clinicians regarding medication adherence assessment. METHOD: Thirty-one child and adolescent outpatients with MDD who enrolled in a 12-week open trial of fluoxetine had their antidepressant medication adherence assessed at each visit, using EM, pill counts, and parent and patient medication diaries. Depression severity was assessed by the Children's Depression Rating Scales-Revised at each visit. RESULTS: Twelve-week least squares mean estimates of medication adherence for the entire sample was high, regardless of the adherence assessment method, although the overall adherence among the four methods (EM, pill, parent diary, patient diary) was significantly different (87.5% vs. 90.6% vs. 93.1% vs. 93.3%, respectively, p=0.0002). Adjusted mean symptom severity was significantly lower for the EM "adherent" group than for the EM "nonadherent" group over the 12 weeks of treatment (35.6 vs. 43.8, p=0.008). CONCLUSION: Overall, EM medication adherence for the depressed youth in this study is high. Compared with EM, there is a tendency of pill counts and medication diaries to overestimate medication adherence. However, pill count adherence better approximates EM adherence, and compliance with returning medication diaries is poor. Youth who are adherent to fluoxetine treatment have lower symptom severity over the course of treatment. Recommendations are provided.

Psychometric properties of the Quick Inventory of Depressive Symptomatology in adolescents.

OBJECTIVE: The clinician-rated (QIDS-C16) and self-report (QIDS-SR16) versions of the 16-item Quick Inventory of Depressive Symptomatology have been extensively examined in adult populations. This study evaluated both versions of the QIDS and the 17-item Children's Depressive Rating Scale - Revised (CDRS-R) in an adolescent outpatient sample. METHOD: Both the QIDS-C16 and QIDS-SR16 were completed for the adolescents. Three different methods were used to complete the QIDS-C16: (a) adolescents' responses to clinician interviews; (b) parents' responses to clinician interview; and (c) a composite score using the most pathological response from the two interviews. Both classical and item response theory methods were used. Factor analyses evaluated the dimensionality of each scale. RESULTS: The sample included 140 adolescent outpatients. All versions of the QIDS, save the parent interview, and the CDRS-R were very reliable (α ≥ 0.8). All four versions of the QIDS are reasonably effective and unidimensional. The CDRS-R was clearly at least two-dimensional. The CDRS-R was the most discriminating among low and extremely high levels of depression. The QIDS-SR16 was the most discriminating at moderate levels of depression. There was no relation between the QIDS scores and concurrent Axis III comorbidities. CONCLUSION: The QIDS-C16 and the QIDS-SR16 are suitable for use in adolescents.

Attention training for school-aged children with ADHD: results of an open trial.

OBJECTIVE: The article discusses a feasibility study conducted to examine whether Pay Attention!, an intervention training sustained, selective, alternating, and divided attention, could be utilized in a clinical setting with children diagnosed with ADHD, and whether children who received the intervention made attention and executive functioning gains. METHOD: After a diagnostic and baseline evaluation, 23 school-aged children with ADHD participate in up to 16 sessions of Pay Attention! and the outcomes are evaluated. RESULTS: Results show the intervention is feasible to administer and acceptable to participants. Parents and clinicians rate fewer ADHD symptoms following the intervention and report improvements in executive function. Child performance on neuropsychological tests showed improvements in fluid reasoning and cognitive flexibility and working memory. CONCLUSION: The findings suggest that a randomized clinical trial of Pay Attention! is warranted to investigate its viability as a treatment for attention and executive functioning deficits in ADHD.

The Treatment for Adolescents With Depression Study (TADS): outcomes over 1 year of naturalistic follow-up.

OBJECTIVE: The Treatment for Adolescents With Depression Study (TADS) evaluates the effectiveness of fluoxetine, cognitive-behavioral therapy (CBT), and their combination in adolescents with major depressive disorder. The authors report effectiveness outcomes across a 1-year naturalistic follow-up period. METHOD: The randomized, controlled trial was conducted in 13 academic and community sites in the United States. Stages I, II, and III consisted of 12, 6, and 18 weeks of acute, consolidation, and continuation treatment, respectively. Following discontinuation of TADS treatments at the end of stage III, stage IV consisted of 1 year of naturalistic follow-up. The participants were 327 subjects between the ages of 12 and 17 with a primary DSM-IV diagnosis of major depressive disorder. No TADS treatment was provided during the follow-up period; treatment was available in the community. The primary dependent measures, rated by an independent evaluator blind to treatment status, were the total score on the Children's Depression Rating Scale-Revised and the rate of response, defined as a rating of much or very much improved on the Clinical Global Impressions improvement measure. RESULTS: Sixty-six percent of the eligible subjects participated in at least one stage IV assessment. The benefits seen at the end of active treatment (week 36) persisted during follow-up on all measures of depression and suicidality. CONCLUSIONS: In contrast to earlier reports on short-term treatments, in which worsening after treatment is the rule, the longer treatment in the TADS was associated with persistent benefits over 1 year of naturalistic follow-up.

DATE: Depressed adolescents treated with exercise: Study rationale and design for a pilot study.

There is an important need for non-medication interventions for depressed youth. The aim of this study is to evaluate the feasibility of using a standardized aerobic exercise regime to treat non-medicated clinically depressed adolescents based on adherence and completion rates, including 1) establishing effect sizes for the primary outcomes including the Chidren's Depression Rating Scale - Revised (CDRS-R) and Actical (energy expenditure data) as well as selected secondary outcomes; (e.g., Clinical Global Improvement, depression rating scales, exercise logs, attitudes), and 2) determining whether moderate to strenuous exercise (12 kcal/kg/week [KKW]) versus a control stretching activity (<4 KKW) for 12 weeks leads to a clinically meaningful reduction in depressive symptoms and/or improved psychosocial functioning. The challenge is to develop an exercise intervention that can motivate a typically sedentary depressed adolescent to exercise on a regular basis. The goal is to demonstrate that exercise alone can provide an important and effective non-medication intervention for adolescent depression. This paper reports on the rationale and design of a pilot study which aims to inform the design of a larger trial to evaluate the efficacy of aerobic exercise to treat adolescent depression. After describing the case for exercise within the broader context of the prevalence of adolescent depression and other treatments, the paper describes the intervention and procedures for data collection.

Early prediction of acute antidepressant treatment response and remission in pediatric major depressive disorder.

OBJECTIVE: : Less than half of youths achieve remission (minimal to no symptoms) after acute antidepressant treatment. Early identification of who will or will not respond to treatment and achieve remission may help clinicians formulate treatment decisions and shorten the time spent on ineffective treatments. In a prospective open-label fluoxetine study, we investigate indicators of acute treatment response and remission. METHOD: : One hundred sixty-eight children and adolescents, ages 7 to 18 years, with primary diagnoses of major depressive disorder received 12 weeks of fluoxetine treatment. The youths were evaluated using the Kiddie Schedule for Affective Disorders and Schizophrenia. The outcome measure included the Children's Depression Rating Scale-Revised. RESULTS: : Positive first-degree family history of depression was the only baseline demographic and clinical characteristic that predicted a favorable treatment response (p =.01). The rate of symptom improvement, however, is a good indicator of acute treatment response. A significant symptom reduction (approximately 50%) by week 4 is needed to achieve remission at the end of acute treatment. CONCLUSIONS: : This study demonstrated that the rate of symptom improvement during early weeks of acute fluoxetine treatment is a good indicator of remission. Treatment approach may be reevaluated and modified as early as week 4 during acute treatment.Clinical trials registration information-Determining Optimal Continuation Treatment Duration for Depressed Children and Adolescents. URL: http://www.clinicaltrials.gov. Unique identifier: NCT00332787.