Retrospective chart review of catatonia in child and adolescent psychiatric patients.

OBJECTIVE: Identify the frequency of catatonia among at-risk children and adolescents receiving psychiatric treatment. METHOD: Subjects were children and adolescents (<18 years), who had received psychiatric treatment at a University Hospital during 2004-2009, and were diagnosed with disorders with known risk for catatonia or displayed symptoms suggestive of catatonia. Approval was obtained from the Investigational Review Board (IRB). The first 101 (n = 101) subjects were selected among 570 subjects identified by psychiatric diagnoses: any pervasive developmental disorder, psychosis-NOS (Not Otherwise Specified), intermittent explosive disorder, mental retardation, catatonia and neuroleptic malignant syndrome. Subjects met study-defined criteria for catatonia, if they had three or more of the following symptoms: unexplained agitation/excitement, disturbed or unusual movements, reduced movements, repetitive or stereotyped movements, or reduced or loss of speech. RESULTS: Eighteen (17.8%) subjects, among a group suspected to be at a higher risk for catatonia, met the study-defined criteria for this syndrome. However, only two subjects had been diagnosed by their treatment providers. Higher rates of intellectual disability and aggression were found among the group that met study-criteria. CONCLUSION: We concluded that catatonia is under recognized and undertreated among children and adolescents receiving psychiatric treatment.

Prediction of positive outcomes for adolescent psychiatric inpatients.

OBJECTIVE: To identify individual, parent/family, and treatment follow-through predictors of outcome for adolescent psychiatric inpatients 6 months after hospital discharge. METHOD: Eighty-nine adolescents participated in a comprehensive baseline evaluation during psychiatric hospitalization. Baseline measures included the Diagnostic Interview Schedule for Children, Social Adjustment Inventory for Children and Adolescents, Reynolds Adolescent Depression Scale (RADS), and Suicidal Ideation Questionnaire-Junior (SIQ-Jr). Structured telephone follow-up interviews assessed treatment follow-through, suicidal behaviors, rehospitalizations, living changes, and social adaptive functioning. The RADS and SIQ-Jr were also readministered. RESULTS: Baseline indices of adolescent functioning emerged as the strongest predictors of outcomes. Hierarchical multiple regression analyses indicated that baseline depression severity, a cluster of parent/family indices, and medication follow-through were significant predictors of outcome depression severity. Baseline social adaptive functioning, presence/absence of conduct disorder, and medication follow-through were significant predictors of outcome social adaptive functioning. CONCLUSIONS: The nature and course of adolescent psychopathology was difficult to disrupt, with baseline characteristics as the strongest predictors of outcome. Nevertheless, the significance of medication follow-through as a predictor suggests that treatment-related gains are possible.

Aggressive behavior in clinically depressed adolescents.

OBJECTIVE: To investigate the prevalence and characteristics of aggressive behavior in adolescent inpatients and outpatients with major depressive disorder (MDD). Differences between males and females in prevalence and type of aggression, and level of parent-child agreement in report of aggression, were analyzed. METHOD: Participants were 74 adolescents with MDD, aged 13 to 17 years. The Structured Clinical Interview for DSM-IV Axis I Disorders was used to identify MDD. Adolescents' aggressive behavior was assessed using an adapted version of the Brown-Goodwin Assessment for Lifetime History of Aggression; the Measure of Aggression, Violence, and Rage in Children; and the Buss-Durkee Hostility Inventory-Adapted Version. RESULTS: Results indicate high levels of aggressive behavior in adolescents with MDD. Amount and type of aggression did not differ by gender. Results indicate poor correspondence between parent and adolescent reports of aggression, which was most marked for females. CONCLUSIONS: Aggressive behaviors are highly prevalent in depressed youths, with similar types and levels evident in males and females. Parents tend to under-report and may not be cognizant of aggressive behavior that occurs outside the home, particularly for females.

Suicidal adolescents after hospitalization: parent and family impacts on treatment follow-through.

OBJECTIVE: To help determine optimal strategies for treating suicidal adolescents, the authors studied family predictors of compliance with recommended psychotropic medication monitoring, individual therapy, and parent guidance/family therapy sessions. METHOD: Sixty-six hospitalized, suicidal adolescents participated in a comprehensive diagnostic evaluation and depression/suicidality assessment. Family/parental assessment measures were the Family Assessment Device, Social Adjustment Inventory for Children and Adolescents (parent-adolescent subscales), Symptom Checklist-90-Revised, and Social Adjustment Scale-Self Report. Follow-up evaluation, 6 months posthospitalization, consisted of structured telephone interviews assessing treatment follow-through. RESULTS: Compliance with recommended medication follow-up (66.7%) and individual therapy (50.8%) was better than compliance with parent guidance/family therapy (33.3%) sessions. The most dysfunctional families and those with the least involved/affectionate father-adolescent relationships had the poorest follow-through with parent guidance/family therapy. Mothers' depressive and paranoid symptoms were linked with less adolescent individual therapy and family therapy follow-through. Mothers' hostility was associated with less medication follow-up. CONCLUSIONS: Follow-through was best for medication and individual therapy. Multiple family/parental predictors of poor follow-through suggest the need for alternative or supplemental treatment strategies.

Depressed adolescents with a history of sexual abuse: diagnostic comorbidity and suicidality.

OBJECTIVE: To determine the nature of comorbid psychopathology and suicidality associated with a history of sexual abuse in depressed adolescents. METHOD: Twenty-four depressed adolescent inpatients with a history of sexual abuse were compared with a matched control group of 24 depressed adolescent inpatients on measures of depression, suicidal ideation and behavior, and posttraumatic stress disorder (PTSD) symptoms. RESULTS: Depressed adolescents with a history of sexual abuse had a higher prevalence of comorbid PTSD than did those without such a history. Chronicity and severity of abuse were significant contributors to a PTSD diagnosis. No differences were found in depression severity, specific depressive symptoms, or suicidal behavior. CONCLUSION: Comorbidity of depressive disorders and PTSD are common among adolescent inpatients with a history of chronic sexual abuse. The need for thorough assessment of depression and PTSD with appropriate interventions for sexually abused adolescents is clear.

Predictors of comorbid alcohol and substance abuse in depressed adolescents.

OBJECTIVE: To identify clinical profiles discriminating depressed adolescents on the basis of comorbid alcohol/substance use disorders and to determine whether or not profiles with high predictive power are gender-specific. METHOD: One hundred three adolescent inpatients with major depression (65 girls, 38 boys) participated in a comprehensive diagnostic evaluation. Independent assessments of depression, suicidality, and psychosocial adjustment were conducted using well-validated instruments. RESULTS: Gender-specific clinical profiles were identified that predicted alcohol/substance abuse in depressed adolescents with high levels of sensitivity (90%). The significant discriminant function for depressed girls included the following predictors: longer depressive episodes, more conduct problems and psychosocial impairment, and more active involvement in relationships with boys. The significant discriminant function for depressed boys included conduct disorder, older age, and schoolwork problems. These profiles correctly identified most depressed adolescents with comorbid alcohol/substance abuse. CONCLUSIONS: Given that alcohol abuse and depression are associated with highly impaired social functioning and increased risk of self-harm, sensitivity in case identification is critical. Clinicians should conduct comprehensive assessments of alcohol/substance abuse in depressed adolescents with the identified clinical profiles.

Utility of the head computerized tomography scan in child and adolescent psychiatry.

Despite the widespread use of computerized tomography (CT) in child and adolescent psychiatry, studies have not looked at its overall usefulness in a clinical setting. In this report, the authors examined 122 inpatients who had CT scans of the head. Only 27 patients had an abnormal CT scan. None of the patients had a change made in the diagnosis or treatment as a result of the scan findings. The authors suggest that routine CT scans of the head in child and adolescent inpatients is of limited value. In view of the rising costs of medical investigations, and the risk of irradiation to the developing brain, they suggest the need for clear indications for this procedure in clinical child and adolescent psychiatry.

Serotonin dysregulation in adolescents with major depression: hormone response to meta-chlorophenylpiperazine (mCPP) infusion.

This study examined central serotonin disturbance, as reflected by neuroendocrine hormones, among adolescents with major depression. Prolactin, cortisol, and growth hormone were measured following the infusion of a serotonin agonist, meta-chlorophenylpiperazine (mCPP). Twelve (M=6, F=6) medication-free adolescents with major depression (MDD) were compared with 12 (M=6, F=6) matched normal control subjects, ranging in age from 13 to 17 years. Baseline evaluations and a battery of laboratory tests were completed. mCPP, 0.1 mg/kg i. v., was administered in a placebo-controlled design. Analyses of the neuroendocrine hormones revealed that the depressed group had a higher baseline prolactin level and an augmented prolactin response to mCPP challenge than did the control group. The depressed group experienced a sharper baseline-cortisol decline between 08.00 and 11.00 h, and compared to control subjects they displayed an augmented response to the challenge. The depressed group reported more side effects than the control group during saline infusion, but not during mCPP infusion. Findings suggest that depressed adolescents have an elevated baseline prolactin level, and also experience enhanced prolactin and cortisol responses to the serotonergic challenge. These preliminary findings will be confirmed during our ongoing study.

An open clinical trial of trazodone in aggressive children.

ABSTRACT In open clinical trials that incorporated an ABA design, trazodone was found to be effective in treating aggression in three children (ages 7-9) whose primary diagnoses were disruptive behavior disorders. In two patients, trazodone 75 mg daily was used alone, and in one subject the same dose was used in combination with l-tryptophan 1000 mg daily. At a mean dose of trazodone 0.35 mg/kg daily, significant improvement in aggressive behavior was noted within 7-days. No major problems with side effects were noted, though an increased frequency of penile erections was reported by the 9-year-old during the first week of treatment. Trazodone did not appear to act through its antidepressant or anti-ADHD properties. The efficacy of this selective serotonin reuptake inhibitor in treating aggressive symptoms in children is consistent with previous findings that implicate decreased levels of serotonin in the etiology of aggression.

Cognitive side effects of electroconvulsive therapy in adolescents.

OBJECTIVE: The primary aim of this study was to determine the presence of cognitive impairments among adolescents treated with electroconvulsive therapy (ECT) and whether these deficits would persist several months following the treatment. METHODS: Retrospective data resulting from standard clinical care of a convenience sample with naturalistic follow-up were used. Subjects were 16 adolescents (13 females, 3 males; mean age = 15.9 +/- 1.6 years) hospitalized with a mood disorder (unipolar depression = 14, bipolar depression = 2). Cognitive tests administered prior to ECT were compared with results at 7.0 +/- 10.3 days following the last treatment and with a second testing at 8.5 +/- 4.9 months after the last treatment. RESULTS: Comparison of pre-ECT and the first post-ECT testing administered during the first 10 days of the treatment yielded significant impairments of concentration and attention, verbal- and visual-delayed recall, and verbal fluency. A complete recovery of these functions was noted at the second post-ECT testing. There was no deficit in the ability to problem solve during the initial or the subsequent testing. CONCLUSION: Cognitive parameters found to be impaired during the first few days of ECT recovered over several months following the treatment. Therefore, there was no evidence of long-term damage to concentration, attention, verbal and visual memory, or verbal fluency. There were no impairments of motor strength and executive processing, even during the early (within 7-10 days) post-ECT period. These results should be regarded as preliminary, awaiting confirmation with larger samples.

Myoclonus during prolonged treatment with sertraline in an adolescent patient.

A 15-year-old female adolescent with depression developed myoclonus after uninterrupted treatment with sertraline over 6 years. She was also receiving methylphenidate. Withdrawal of sertraline and continuation of methylphenidate did not result in any improvement. Treatment with valproic acid resulted in improvement of the movement disorder. This report suggests that myoclonus may be a side effect of sertraline in some adolescents. Further, we hypothesized that extended treatment over several years, young age, and a compromised central nervous system due to underlying disorders may be risk factors for the development of this side effect.

Electroconvulsive treatment of a bipolar adolescent postcraniotomy for brain stem astrocytoma.

This is the first reported use of electroconvulsive treatment (ECT) in an adolescent with bipolar mania who had been treated with craniectomy for an intracranial neoplasm. The reported case is of a 16-year-old girl with a history of brain stem glioma (pontomesencephalic astrocytoma) diagnosed at 13 years of age. She presented in a psychiatric emergency room with suicidal ideation, depressed mood, irritability, olfactory hallucinations, early insomnia, grandiosity, and guilt. Her symptoms failed to respond to a trial of an antidepressant, mood stabilizer alone, and mood stabilizer in conjunction with a neuroleptic. The decision to use ECT was based on suicidal ideation, extreme disinhibition, and danger to self and others. Significant improvement in mood and remission in psychosis were noted after the eighth treatment. Comparison of 2-week pre-ECT and 3-month post-ECT cognitive testing revealed no change in IQ. This report highlights rapid response and the ability to tolerate ECT in an adolescent diagnosed with bipolar disorder, who had also been treated with radiation and craniotomy.

Electroconvulsive treatment in adolescents with pharmacotherapy-refractory depression.

The effectiveness and safety of ECT in pharmacotherapy-refractory depression was examined in 11 hospitalized adolescents (ages 16.3 +/- 1.7 years, 10 females) with a primary DSM-III-R diagnosis of mood disorder, which had failed to respond to three or more adequate trials of antidepressant pharmacotherapy. After a thorough diagnostic evaluation, patients received a course of ECT involving 11.2 +/- 2.0 (range 8-15) administrations. ECT was commenced with bilateral treatment in 2 adolescents and nondominant right electrode placement in 9 patients; 5 of the 9 patients were subsequently changed to bilateral treatment. All 11 patients improved to a clinically significant degree. Significant improvements were noted in scores on the Children Depression Rating Scale-Revised (CDSR-R) and the Global Assessment of Functioning Scale (GAF) (p < 0.05). Euthymia, defined as CDRS-R score < or = 40, was achieved by 64% (7/11) of patients. The Mini-Mental State Examination showed no significant decline in cognitive functioning. Neuropsychological testing completed in 5 subjects both before ECT and 1-5 days after the last treatment, indicated a significant decline in attention, concentration, and long-term memory search. Minor side effects, experienced within the first 12 hours of treatment, were headache (80% of patients) and nausea/vomiting (64%). The potentially serious complication of tardive seizure (after full recovery of consciousness) occurred in 1 adolescent. Prolonged seizures (> 2.5 minutes) were noted in 7 of the 11 patients (9.6% of the 135 ECT administrations). Pending further research on ECT in youth, it is recommended that ECT should only be administered to youth in hospital settings, that all regularly administered psychotropic medications (including antidepressants) be discontinued before ECT and restarted after the final administration of ECT, and that physicians be aware that 12 treatments are usually sufficient, but that 15 treatments may occasionally be necessary for treating depressed adolescents. With the understanding that scientific evaluation of ECT in youth is lacking, it appears that ECT can be an effective and relatively safe treatment for depressed adolescents who have failed to respond to antidepressant pharmacotherapy.

Suicide contagion among adolescents during acute psychiatric hospitalization.

OBJECTIVE: The study investigated whether exposure to other suicidal adolescents led to suicide contagion among patients hospitalized on an acute adolescent psychiatry unit. It also examined whether some adolescents express more suicidality during hospitalization than before admission. METHODS: Fifty-seven adolescents with a range of diagnoses admitted to a university-based psychiatric inpatient unit were assessed for suicidality at hospital admission and discharge using the Spectrum of Suicide Behavior scale and the Suicidal Ideation Questionnaire-Jr. Suicidal intent or behavior was the primary reason for admission of 58 percent of the patients. RESULTS: Despite many patients' severe suicide risk at hospital admission, 94 percent expressed no active suicidal intent and engaged in no behavior that could be considered suicidal during hospitalization. Four patients engaged in possibly suicidal, self-cutting behaviors; however, these incidents did not cluster in time. Fourteen patients (26 percent) expressed a significant increase in suicidal ideation during hospitalization, but the increase was not associated with study measures of exposure to other suicidal adolescents. CONCLUSIONS: Contagion of suicidal behaviors may not be a frequent or significant problem on acute adolescent inpatient units, although the phenomenon of increased suicidal ideation among some inpatients warrants further study.

Diagnosis and assessment of depression and suicidality using the NIMH Diagnostic Interview Schedule for Children (DISC-2.3).

The diagnostic Interview Schedule for Children (DISC-2.3) was studied in a sample of 265 adolescent inpatients to determine type and concurrent validity of depressive symptoms and depressive disorder diagnoses for different DISC-2.3 informants (parent, adolescent, both). The Children's Depression Rating Scale--Revised, Reynolds Adolescent Depression Scale (RADS), Suicide Ideation Questionnaire--Junior, Spectrum of Suicide Behavior Scale, and clinical consensus diagnoses were used to assess concurrent validity. Results indicated that (1) parents, compared to adolescents, reported a higher prevalence of all depressive symptoms with the exception of weight change; (2) DISC-2.3 depressive and suicidality symptoms were related positively to independent validating criteria for all informant conditions, suggesting good concurrent validity; (3) the DISC-2.3 both informant condition correctly identified the most depressive disorders; and (4) the parent, but not the adolescent, DISC-2.3 Informant condition contributed to the prediction of clinical consensus diagnoses of depression after taking into account RADS scores.

Adolescent attitudes about death in relation to suicidality.

This study examined psychiatrically disturbed adolescents' history of exposure to suicide attempts, completions, and other deaths in relation to attitudes about life and death. A primary goal of the study was to study the mediating processes involved in the impact of loss on suicidality. Adolescents who experienced the suicide of a friend or immediate family member reported a weaker attraction to life and stronger attraction to death than adolescents lacking this experience. Exposure to attempted suicide resulted in attitudes indicating a stronger attraction to death and repulsion by life. We conclude that a comprehensive history of loss and assessment of current attitudes toward death are important aspects of evaluation and subsequent treatment of at-risk adolescents.

A prospective study of adolescent suicidal behavior following hospitalization.

Identification of factors associated with adolescent suicidal behavior following psychiatric hospitalization would facilitate development of effective aftercare interventions. This prospective study identified specific predictors of suicidal behavior in 100 adolescents during a 6-month follow-up period. Standardized baseline assessments and structured follow-up telephone interviews were conducted with adolescents and their guardians. Eighteen percent of adolescents reported suicidal behavior during the follow-up period, primarily of low medical lethality and minimal or ambivalent suicidal intent. This behavior was associated with suicidal thoughts, family dysfunction, and dysthymia. It was not associated with initial posthospitalization treatment compliance. Implications of these findings are discussed.

Comorbidity of autistic disorder in children and adolescents.

Although considerable research has been done on various aspects of autism, information about the prevalence of coincident psychiatric disorders that may complicate this syndrome, is negligible. In this paper, we present preliminary data on the presentation of other psychiatric disorders in children and adolescents with autism. Out of an outpaticent sample of 68 autistic children and adolescents, 6 (9%) presented with an associated psychiatric disorder. Depression was the most common diagnosis. None of the patients was given a diagnosis of schizophrenia. Clinical and research implications of the findings are discussed.