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.

Fluoxetine versus placebo in preventing relapse of major depression in children and adolescents.

OBJECTIVE: The authors compared fluoxetine and placebo in continuation treatment to prevent relapse of major depressive disorder in children and adolescents. METHOD: After a detailed evaluation, children and adolescents 7-18 years of age with major depressive disorder were treated openly with fluoxetine. Those who had an adequate response after 12 weeks, as indicated by a Clinical Global Impression improvement score of 1 or 2 and a decrease of at least 50% in Children's Depression Rating Scale-Revised score, were randomly assigned to receive fluoxetine or placebo for an additional 6 months. The primary outcome measures were relapse and time to relapse. Relapse was defined as either a score of 40 or higher on the Children's Depression Rating Scale with a history of 2 weeks of clinical deterioration, or clinical deterioration as judged by the clinician. Additional analyses were conducted with relapse defined only as a score of 40 or higher on the Children's Depression Rating Scale. RESULTS: Of 168 participants enrolled in acute fluoxetine treatment, 102 were randomly assigned to continuation treatment with fluoxetine (N=50) or placebo (N=52). Of these, 21 participants (42.0%) in the fluoxetine group relapsed, compared with 36 (69.2%) in the placebo group, a significant difference. Similarly, under the stricter definition of relapse, fewer participants in the fluoxetine group relapsed (N=11; 22.0%) than in the placebo group (N=25; 48.1%). Time to relapse was significantly shorter in the placebo group. CONCLUSIONS: Continuation treatment with fluoxetine was superior to placebo in preventing relapse and in increasing time to relapse in children and adolescents with major depression.

Remission of maternal depression: relations to family functioning and youth internalizing and externalizing symptoms.

Family functioning and parenting were hypothesized to mediate the relation between remission of maternal depression and children's psychosocial adjustment. Participants were 114 mother-child dyads participating in the Sequenced Treatment Alternatives to Relieve Depression Child 3-month follow-up. All mothers had been diagnosed with major depressive disorder and were treated initially with citalopram; 33% of mothers experienced remission of depressive symptoms. Youth ranged in age from 7 to 17. Remission of maternal depression was associated with changes in children's reports of their mothers' warmth/acceptance, which in turn partially mediated the relation between maternal depression remission and youth internalizing symptoms, accounting for 22.9% of the variance.

Switching to another SSRI or to venlafaxine with or without cognitive behavioral therapy for adolescents with SSRI-resistant depression: the TORDIA randomized controlled trial.

CONTEXT: Only about 60% of adolescents with depression will show an adequate clinical response to an initial treatment trial with a selective serotonin reuptake inhibitor (SSRI). There are no data to guide clinicians on subsequent treatment strategy. OBJECTIVE: To evaluate the relative efficacy of 4 treatment strategies in adolescents who continued to have depression despite adequate initial treatment with an SSRI. DESIGN, SETTING, AND PARTICIPANTS: Randomized controlled trial of a clinical sample of 334 patients aged 12 to 18 years with a primary diagnosis of major depressive disorder that had not responded to a 2-month initial treatment with an SSRI, conducted at 6 US academic and community clinics from 2000-2006. INTERVENTIONS: Twelve weeks of: (1) switch to a second, different SSRI (paroxetine, citalopram, or fluoxetine, 20-40 mg); (2) switch to a different SSRI plus cognitive behavioral therapy; (3) switch to venlafaxine (150-225 mg); or (4) switch to venlafaxine plus cognitive behavioral therapy. MAIN OUTCOME MEASURES: Clinical Global Impressions-Improvement score of 2 or less (much or very much improved) and a decrease of at least 50% in the Children's Depression Rating Scale-Revised (CDRS-R); and change in CDRS-R over time. RESULTS: Cognitive behavioral therapy plus a switch to either medication regimen showed a higher response rate (54.8%; 95% confidence interval [CI], 47%-62%) than a medication switch alone (40.5%; 95% CI, 33%-48%; P = .009), but there was no difference in response rate between venlafaxine and a second SSRI (48.2%; 95% CI, 41%-56% vs 47.0%; 95% CI, 40%-55%; P = .83). There were no differential treatment effects on change in the CDRS-R, self-rated depressive symptoms, suicidal ideation, or on the rate of harm-related or any other adverse events. There was a greater increase in diastolic blood pressure and pulse and more frequent occurrence of skin problems during venlafaxine than SSRI treatment. CONCLUSIONS: For adolescents with depression not responding to an adequate initial treatment with an SSRI, the combination of cognitive behavioral therapy and a switch to another antidepressant resulted in a higher rate of clinical response than did a medication switch alone. However, a switch to another SSRI was just as efficacious as a switch to venlafaxine and resulted in fewer adverse effects. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT00018902.

Course and Severity of Maternal Depression: Associations with Family Functioning and Child Adjustment.

Number of lifetime episodes, duration of current episode, and severity of maternal depression were investigated in relation to family functioning and child adjustment. Participants were the 151 mother-child pairs in the Sequenced Treatment Alternatives to Relieve Depression (STAR*D) child multi-site study. Mothers were diagnosed with Major Depressive Disorder; children (80 males and 71 females) ranged in age from 7 to 17 years. Measures of child adjustment included psychiatric diagnoses, internalizing and externalizing symptoms, and functional impairment. Measures of family functioning included family cohesion, expressiveness, conflict, organization, and household control; parenting measures assessed maternal acceptance and psychological control. Children of mothers with longer current depressive episodes were more likely to have internalizing and externalizing symptoms, with this association being moderated by child gender. Mothers with more lifetime depressive episodes were less likely to use appropriate control in their homes.

Research knowledge among the participants in the Treatment for Adolescents With Depression Study (TADS).

OBJECTIVE: We examined the extent to which parents and adolescents participating in the Treatment for Adolescents With Depression Study (TADS) understood key aspects of the study. METHOD: TADS was a clinical trial comparing the effectiveness of fluoxetine, cognitive-behavioral therapy (CBT), their combination, and placebo in 439 adolescents (12-17 years old) with major depressive disorder. Six weeks after starting treatment, adolescents and their parents were asked to complete a questionnaire about critical elements of the trial. RESULTS: Completion rate was 67.2% for adolescents (N = 295) and 73.6% for parents (N = 323). More than 90% of the completers knew of the main purpose of the trial, possible assignment to placebo, and their right to withdraw participation at any time. However, about one third overall (and 49% in the CBT group) described TADS as "education" rather than "research." Of 12 questions, the mean number of correct answers was 10.3 (SD 1.7) among adolescents and 11.2 (SD 1.2) among parents (p <.0001). The most frequently stated reason for TADS participation was the pursuit of high-quality care. CONCLUSIONS: Most parents and adolescents were well-informed research participants. Difficulties in appreciating the research nature of the trial, however, emerged, especially among participants assigned to psychotherapy. Parents were overall better informed than adolescents.

A psychometric evaluation of the CDRS and MADRS in assessing depressive symptoms in children.

OBJECTIVE: This study compared the psychometric properties of the Children's Depression Rating Scale-Revised (CDRS-R) and the Montgomery-Asberg Depression Rating Scale (MADRS) in children with major depressive disorder. METHOD: Children (N = 96; ages 8 to 11 years inclusive) with nonpsychotic major depressive disorder were enrolled. Participants were part of a multisite, outpatient, randomized, placebo-controlled, 9-week trial of fluoxetine (10 mg/day for the first week and 20 mg/day thereafter). The CDRS-R and MADRS were completed based on clinician interviews with both parents and children. Classic test theory and item response theory analyses were conducted. RESULTS: The MADRS and CDRS-R total scores were correlated at baseline (r = 0.51) and at study exit (r = 0.85). Cronbach's alpha was .86 (CDRS-R) and .82 (MADRS) at exit. The effect sizes for change from baseline to exit between the fluoxetine and placebo groups were 0.78 (CDRS-R) and 0.61 (MADRS). There was agreement between the CDRS-R and MADRS in the declaration of treatment response (50% improvement from baseline to exit) in 84.2% of children. Test information function favored the CDRS-R. CONCLUSIONS: The CDRS-R showed greater effect size for differentiating drug and placebo and better test information than the MADRS in this study of depressed children.

Texas Children's Medication Algorithm Project: update from Texas Consensus Conference Panel on Medication Treatment of Childhood Major Depressive Disorder.

OBJECTIVE: To revise and update consensus guidelines for medication treatment algorithms for childhood major depressive disorder based on new scientific evidence and expert clinical consensus when evidence is lacking. METHOD: A consensus conference was held January 13-14, 2005, that included academic clinicians and researchers, practicing clinicians, administrators, consumers, and families. The focus was to review, update, and incorporate the most current data to inform and recommend specific pharmacological approaches and clinical guidance for treatment of major depressive disorder in children and adolescents. RESULTS: Consensually agreed on medication algorithms for major depression (with and without psychosis) and comorbid attention-deficit disorders were updated. These revised algorithms also incorporated approaches to address issues of suicidality, aggression, and irritability. Stages 1, 2, and 3 of the algorithm consist of selective serotonin reuptake inhibitor and norepinephrine serotonin reuptake inhibitor medications whose use is supported by controlled, acute clinical trials and clinical experience. Recent studies provide support that selective serotonin reuptake inhibitors in addition to fluoxetine are still encouraged as first-line interventions. The need for additional assessments, precautions, and monitoring is emphasized, as well as continuation and maintenance treatment. CONCLUSIONS: Evidence and expert clinical consensus support the use of selected antidepressants in the treatment of depression in youths. The use of the recommended antidepressant medications requires appropriate monitoring of suicidality and potential adverse effects and consideration of other evidence-based treatment alternatives such as cognitive behavioral therapies.

Do children and adolescents have differential response rates in placebo-controlled trials of fluoxetine?

OBJECTIVE: Recent acute efficacy trials of antidepressants in youth have suggested that high placebo-response rates in children (< 12 years of age) indicate that children may be more responsive to non-specific treatment interventions. Yet, these studies generally have not presented age-specific outcome data. The objective of this study was to compare the efficacy outcomes for children (< 12 years of age) and adolescents (> or = 12 years of age) using the combined data from two previously published double-blind, placebo-controlled trials of fluoxetine. METHODS: Children (< 12 years of age) and adolescents (> or = 12 years of age) with major depressive disorder were randomized to fluoxetine or placebo for 8-9 weeks of treatment. Outcome was assessed using the Children's Depression Rating Scale-Revised (CDRS-R) and Clinical Global Impressions scale. RESULTS: Random regression of the CDRS-R showed a treatment group by age group interaction (F(1,338)=4.10, P=.044), indicating that the treatment effect was significantly more pronounced in children than adolescents. Within children, response at exit to fluoxetine was significantly better than placebo (56.9% vs 33.3%; P=.009). Adolescent response rates at exit were not significantly different between the groups (51.1% vs 38.6%; P=.128). Remission rates were low for both groups. CONCLUSION: In the combined fluoxetine trials, drug-placebo difference was greater in children compared with adolescents. Contrary to expectations, the placebo-response rate was lower in the children than the adolescents.

Sex and age differences in sleep macroarchitecture in childhood and adolescent depression.

SUBJECT OBJECTIVE: To evaluate age and sex differences in sleep macroarchitecture in children and adolescents with major depressive disorder. DESIGN: Ninety-seven (50 F, 47 M) symptomatic unmedicated depressed outpatients were compared with 76 healthy controls (42 F, 34 M) matched for age and sex. SETTING: Participants spent 2 consecutive nights in the sleep laboratory. PARTICIPANTS: One hundred seventy-three children and adolescents, aged 8 to 18 years. MEASUREMENTS AND RESULTS: Significant group-by-age-by-sex interactions were evident for total sleep period, percentage of Stage 1 sleep, percentage of Stage 2, percentage of slow-wave sleep, and rapid eye movement (REM) sleep latency. The depressed adolescent boys had the greatest sleep disturbance with the highest amount of percentage of Stage 1 sleep, the shortest REM latency, and the least percentage of slow-wave sleep and number of minutes of slow-wave sleep in the first non-REM period. There were minimal age differences in sleep parameters between depressed children and adolescent girls. Within age groups, the sex differences were minimal in the healthy controls. The sex differences within the depressed group were substantially larger than controls. CONCLUSIONS: These findings suggest a differential developmental influence on sleep in early-onset depression that is heavily dependent on sex. Sex differences are substantially smaller in healthy individuals compared with those with depression, in agreement with previous studies in depressed adults.

Children of currently depressed mothers: a STAR*D ancillary study.

OBJECTIVE: To assess the current and lifetime prevalence of psychiatric disorders among children of currently depressed mothers and to assess the association of clinical features of maternal depression (i.e., severity, chronicity, and clinical features) with child psychopathology. Mothers were participants in the STAR*D (Sequenced Treatment Alternatives to Relieve Depression) multisite trial, designed to compare effectiveness and acceptability of different treatment options for outpatients with non-psychotic major depressive disorder (MDD). METHOD: Treatment-seeking mothers with a current DSM-IV diagnosis of MDD and with at least 1 child 7 to 17 years old were assessed during a major depressive episode (MDE). For each mother, 1 child was assessed (if a mother had more than 1 child, 1 was randomly selected). Maternal features assessed for this study were history of MDEs, severity of current MDE, comorbid conditions, depressive symptom features, and social functioning. Children were assessed for selected psychiatric diagnoses (Schedule for Affective Disorders and Schizophrenia for School-Age Children-Present and Lifetime Version [K-SADS-PL]), psychopathologic symptoms and social functioning (Child Behavior Checklist), and global functioning (Children's Global Assessment Scale). Data were gathered from December 2001 to April 2004. RESULTS: A large proportion (72%) of mothers were severely depressed (17-item Hamilton Rating Scale for Depression score >/= 22). About a third (34%) of children had a current psychiatric disorder, including disruptive behavior (22%), anxiety (16%), and depressive (10%) disorders. Nearly half (45%) had a lifetime psychiatric disorder, including disruptive behavior (29%), anxiety (20%), and depressive (19%) disorders. Atypical depressive features in the mother were associated with a 3-fold increase in the odds of having a child with depressive (OR = 3.3 [95% CI = 1.2 to 9.5]; p = .02) or anxiety (OR = 2.6 [95% CI = 1.1 to 6.9]; p = .03) disorders. A history of maternal suicide attempts and the presence of comorbid panic disorder with agoraphobia were associated with a 3-fold increase and an 8-fold increase in the odds of depressive disorders in the offspring, respectively. The final model showed significant associations (p

The Texas Children's Medication Algorithm Project: revision of the algorithm for pharmacotherapy of attention-deficit/hyperactivity disorder.

OBJECTIVE: In 1998, the Texas Department of Mental Health and Mental Retardation developed algorithms for medication treatment of attention-deficit/hyperactivity disorder (ADHD). Advances in the psychopharmacology of ADHD and results of a feasibility study of algorithm use in community mental health centers caused the algorithm to be modified and updated. METHOD: We convened a consensus conference of academic clinicians and researchers, practicing clinicians, administrators, consumers, and families to revise the algorithms for the pharmacotherapy of ADHD itself as well as ADHD with specific comorbid disorders. New research was reviewed by national experts, and rationales were provided for proposed changes and additions to the algorithms. The changes to the algorithms were discussed and approved both by the national experts and experienced clinicians from the Texas public mental health system. RESULTS: The panel developed consensually agreed-upon algorithms for ADHD with and without comorbid disorders. The major changes included elimination of pemoline as a treatment option, adding atomoxetine to the algorithm, and refining guidelines for treating ADHD with comorbid depression, aggressive behaviors, and tic disorders. CONCLUSIONS: Medication algorithms for ADHD can be modified to keep abreast of developments in the field. Although these evidence- and consensus-based treatment recommendations may be a useful approach to guide the treatment of ADHD in children, additional research is needed to determine how these algorithms can be used to maximally benefit child outcomes.

Remissions in maternal depression and child psychopathology: a STAR*D-child report.

CONTEXT: Children of depressed parents have high rates of anxiety, disruptive, and depressive disorders that begin early, often continue into adulthood, and are impairing. OBJECTIVE: To determine whether effective treatment with medication of women with major depression is associated with reduction of symptoms and diagnoses in their children. DESIGN: Assessments of children whose depressed mothers were being treated with medication as part of the multicenter Sequenced Treatment Alternatives to Relieve Depression (STAR*D) trial conducted (between December 16, 2001 and April 24, 2004) in broadly representative primary and psychiatric outpatient practices. Children were assessed by a team of evaluators not involved in maternal treatment and unaware of maternal outcomes. Study is ongoing with cases followed at 3-month intervals. SETTING AND PATIENTS: One hundred fifty-one mother-child pairs in 8 primary care and 11 psychiatric outpatient clinics across 7 regional centers in the United States. Children were aged 7 to 17 years. MAIN OUTCOME MEASURES: Child diagnoses based on the Kiddie Schedule for Affective Disorders and Schizophrenia; child symptoms based on the Child Behavior Checklist; child functioning based on the Child Global Assessment Scale in mothers whose depression with treatment remitted with a score of 7 or lower or whose depression did not remit with a score higher than 7 on the Hamilton Rating Scale for Depression. RESULTS: Remission of maternal depression after 3 months of medication treatment was significantly associated with reductions in the children's diagnoses and symptoms. There was an overall 11% decrease in rates of diagnoses in children of mothers whose depression remitted compared with an approximate 8% increase in rates of diagnoses in children of mothers whose depression did not. This rate difference remained statistically significant after controlling for the child's age and sex, and possible confounding factors (P = .01). Of the children with a diagnosis at baseline, remission was reported in 33% of those whose mothers' depression remitted compared with only a 12% remission rate among children of mothers whose depression did not remit. All children of mothers whose depression remitted after treatment and who themselves had no baseline diagnosis for depression remained free of psychiatric diagnoses at 3 months, whereas 17% of the children whose mothers remained depressed acquired a diagnosis. Findings were similar using child symptoms as an outcome. Greater level of maternal response was associated with fewer current diagnoses and symptoms in the children, and a maternal response of at least 50% was required to detect an improvement in the child. CONCLUSIONS: Remission of maternal depression has a positive effect on both mothers and their children, whereas mothers who remain depressed may increase the rates of their children's disorders. These findings support the importance of vigorous treatment for depressed mothers in primary care or psychiatric clinics and suggest the utility of evaluating the children, especially children whose mothers continue to be depressed.

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.

Effect of structured interviews on evaluation time in pediatric community mental health settings.

OBJECTIVE: The purpose of this study was to determine whether a structured interview administered by a master's-level clinician and reported to physicians before an initial evaluation would reduce physicians' evaluation time without compromising diagnostic accuracy or clinical outcomes in a pediatric sample. METHODS: A sample of 225 children and adolescents who were seen in public-sector community facilities was randomly assigned either to receive a structured interview (the Schedule for Affective Disorders and Schizophrenia for School-aged Children-Present and Lifetime Versions) by a trained interviewer before the initial physician visit or to receive assessment as usual. Clinical outcome data were collected prospectively, with follow-up at four months. RESULTS: Physicians' evaluation time was reduced by approximately half among physicians who were given preliminary diagnostic information. Physicians' diagnoses were strongly related to the results of the structured interview. Physicians' having access to previously obtained diagnostic information was associated with better psychosocial functioning at follow-up in terms of peer relations and spare-time activities compared with assessment as usual. CONCLUSIONS: Adding a trained diagnostic interviewer to the clinical team could reduce physicians' initial diagnostic evaluation time and improve diagnostic reliability and psychosocial outcomes.

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.

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.

A feasibility study of the children's medication algorithm project (CMAP) algorithm for the treatment of ADHD.

OBJECTIVE: To determine whether an algorithm for the treatment of attention-deficit/hyperactivity disorder (ADHD) can be implemented in a community mental health center. METHOD: Fifty child and adolescent patients at Texas community mental health centers who met criteria for ADHD were treated according to an algorithm-based disease management program for ADHD. Psychiatrists were trained in the use of the algorithm, and each subject underwent a baseline assessment consisting of a structured interview and standardized rating scales. Subjects were monitored for 4 months. At the end of treatment, the psychiatrists completed the Clinical Global Impression Scale (CGI) and the baseline rating scales were repeated. The primary variables of interest were psychiatrist and family adherence to the algorithm. To examine impact on treatment outcome, the CGI of the algorithm subjects was compared with CGIs based on chart reviews of 118 historical controls. RESULTS: Psychiatrists implemented the major aspects of the algorithm, but the detailed tactics of the algorithm (use of fixed titration of stimulants) were less well adhered to. CONCLUSIONS: An algorithm for the treatment of ADHD can be implemented in a community mental health center.

A feasibility study of the childhood depression medication algorithm: the Texas Children's Medication Algorithm Project (CMAP).

OBJECTIVE: To evaluate the feasibility and impact on clinical response and function associated with the use of an algorithm-driven disease management program (ALGO) for children and adolescents treated for depression with or without attention-deficit/hyperactivity disorder (ADHD) in community mental health centers. METHOD: Interventions included (1). medication algorithms, (2). clinical and technical support for the physician, (3). uniform chart documentation of outcomes, and (4). a patient/family psychoeducation program. Children eligible for entry into the study were referred to the child psychiatrist for initiation or change in medicine. Outcomes of treatment with the ALGO for up to 4 months are presented. Measures of change included clinical symptoms, functioning, and global improvement (Clinical Global Impression Scale). A historical chart cohort from the same clinics was used as a quasi-control. RESULTS: Thirty-nine individuals (depression = 24; comorbid depression with ADHD = 15) were enrolled for treatment with ALGO. One hundred fourteen children were in the control cohort (74 depressed, 40 comorbid). For the ALGO groups, Children's Depression Rating Scale-Revised depression severity scores decreased from 48.2 to 32.5 and Child Adolescent Functioning Assessment Scale function scores improved from 70.3 to 40.9 (all p < or =.0005). Clinical Global Impression Scale severity scores decreased from 5.7 to 3.7 in ALGO compared to only 5.8 to 4.8 in the control (p <.003). CONCLUSIONS: There was clear improvement in clinical symptoms, functioning, and global response with ALGO treatment. The magnitude of the improvement was greater in children and adolescents treated with the ALGO program compared with a historical cohort. These data support the need for controlled studies in larger populations examining the effects of algorithm-driven disease management programs on the clinical outcomes of children with mental illness.

A cross-cultural investigation of cognitions and depressive symptoms in adolescents.

Adolescents (N=2,272) from Hong Kong and the United States provided information regarding their depressive symptoms, cognitions (self-efficacy, negative cognitive errors, and hopelessness), and stressful events between 2 surveys 6 months apart. Depressive symptoms and hopelessness were higher, and self-efficacy and negative cognitive errors were lower in Hong Kong than in the United States. Cognitions were associated with concurrent depressive symptoms and predicted depressive symptoms 6 months later in both cultures. The "reverse" model was also supported with more variance predicted by depressive symptoms to later cognitions than from cognitions to depressive symptoms. There was some support for the hypothesis that self-efficacy is less salient in collective compared with individualistic cultures. These findings extend cognitive theories of depression to a non-Western culture.