Screening for Adverse Childhood Experiences in Adolescents Using the Bright Futures Previsit Questionnaire.

In pediatric primary care, incorporation of existing practice tools into screening for adverse childhood experiences (ACEs) may reduce screening barriers, promoting timely intervention on negative health impacts from childhood trauma. One such screening tool is the Bright Futures Previsit Questionnaire (PVQ). To evaluate the extent to which the PVQ may be used to screen for ACEs, this research aimed to map items related to ACEs from adolescent PVQs against adverse events historically identified as conventional and expanded ACEs. The adolescent PVQs mapped effectively to nine ACEs: adverse neighborhood experiences, bullying, emotional neglect, friend or family substance misuse, household safety, intimate partner violence, interpersonal violence, physical neglect, and sexual abuse. Universal ACE screening can be conducted using adolescent PVQs; however, issues remain regarding the reliability and validity of using the PVQs to identify ACEs, and some ACEs are not effectively assessed using adolescent PVQs.

Are all ADHD medications created equal? Exploring the differences that enable evening dosing.

With more than 30 available stimulant medications, choosing among therapeutic options for attention-deficit/hyperactivity disorder (ADHD) has become increasingly complex and patient specific. All ADHD stimulants owe their action to variants of either amphetamine or methylphenidate, yet formulation and delivery system differences create unique pharmacokinetic and clinical profiles for each medication. A benefit of the diversity within ADHD pharmacotherapy is that it facilitates tailoring treatment to meet patient needs. Historically, there has been a constant among long-acting stimulant options, regardless of formulation, which was morning dosing. The introduction of delayed-release and extended-release methylphenidate (DR/ER-MPH) is the first long-acting stimulant that patients take in the evening, with the clinical effect delayed until awakening in the morning. This paradigm shift has generated questions among clinicians and continued interest in real-world experience and data. This review used available clinical data, real-world evidence, emerging analyses, and clinical experience to evaluate the characteristics of DR/ER-MPH and its clinical utility within the greater context of ADHD medications and to provide clinicians with practical guidance on the use of DR/ER-MPH in children, adolescents, and adults with ADHD.

Expert consensus statement for telepsychiatry and attention-deficit hyperactivity disorder.

Changing practice patterns caused by the pandemic have created an urgent need for guidance in prescribing stimulants using telepsychiatry for attention-deficit hyperactivity disorder (ADHD). A notable spike in the prescribing of stimulants accompanied the suspension of the Ryan Haight Act, allowing the prescribing of stimulants without a face-to-face meeting. Competing forces both for and against prescribing ADHD stimulants by telepsychiatry have emerged, requiring guidelines to balance these factors. On the one hand, factors weighing in favor of increasing the availability of treatment for ADHD via telepsychiatry include enhanced access to care, reduction in the large number of untreated cases, and prevention of the known adverse outcomes of untreated ADHD. On the other hand, factors in favor of limiting telepsychiatry for ADHD include mitigating the possibility of exploiting telepsychiatry for profit or for misuse, abuse, and diversion of stimulants. This Expert Consensus Group has developed numerous specific guidelines and advocates for some flexibility in allowing telepsychiatry evaluations and treatment without an in-person evaluation to continue. These guidelines also recognize the need to give greater scrutiny to certain subpopulations, such as young adults without a prior diagnosis or treatment of ADHD who request immediate-release stimulants, which should increase the suspicion of possible medication diversion, misuse, or abuse. In such cases, nonstimulants, controlled-release stimulants, or psychosocial interventions should be prioritized. We encourage the use of outside informants to support the history, the use of rating scales, and having access to a hybrid model of both in-person and remote treatment.

Attention-Deficit/Hyperactivity Disorder in Children and Adolescents.

Attention-deficit/hyperactivity disorder (ADHD) is a childhood-onset neuro-developmental disorder characterized by persistent inattention, hyperactivity, and impulsivity that impairs functioning of the child/adolescent. Although ADHD is the most commonly seen psychiatric disorder in childhood and adolescence, diagnosis of ADHD in children and adolescents in the United States has grown over the past 20 years, with prevalence rates increasing from 6.1% to 10.2% from 1997 to 2016. The current article describes the epidemiology of ADHD, factors that contribute to successful treatment, and recommendations to improve nursing practice. [Journal of Psychosocial Nursing and Mental Health Services, 56(12), 7-10.].

Communicating with colleagues and patients about acute bipolar disorder.

Patients with bipolar disorder require a collaborative care approach involving primary care doctors, psychiatrists, nurses, social workers, therapists, and other support to manage their illness. Psychiatric mental health nurses and advanced practice nurses provide important psychoeducation to patients regarding their diagnosis, medications, and other treatment strategies. Communication among the care team is critical to ensure that patients are adhering to treatment, being monitored for symptoms and adverse effects, and receiving follow-up and support to improve their functioning.

Recognizing signs and symptoms of bipolar disorder.

Psychiatric mental health nurses and advanced practice nurses play an important role in the assessment and care of patients with bipolar disorder. Using appropriate rating scales and diagnostic criteria can aid in the assessment of patients who present with a variety of symptoms. In this game-based CME activity, you will assume the role of a psychiatric mental health advanced practice nurse who must recognize the signs and symptoms of bipolar disorder and select appropriate treatment for a 20-year-old patient with suicidal thoughts.

Double-blind randomized trial of risperidone versus divalproex in pediatric bipolar disorder: fMRI outcomes.

The aim of this research was to determine the relative effects of risperidone and divalproex on brain function in pediatric mania. This is a double-blind 6-week functional magnetic resonance imaging trial with 24 unmedicated manic patients randomized to risperidone or divalproex, and 14 healthy controls (HCs) matched for IQ and demographic factors (mean age: 13.1±3.3years). A pediatric affective color matching task, in which subjects matched the color of a positive, negative or neutral word with one of two colored circles, was administered. The primary clinical measure was the Young Mania Rating Scale (YMRS). The risperidone group, relative to HC, showed an increase in activation from pre- to post-treatment in right pregenual and subgenual anterior cingulate cortex and decreased activation in bilateral middle frontal gyrus during the negative condition; and decreased activation in left inferior and medial, and right middle frontal gyri, left inferior parietal lobe, and right striatum with positive condition. In the divalproex group, relative to HC, there was an increased activation in right superior temporal gyrus in the negative condition; and in left medial frontal gyrus and right precuneus with the positive condition. Greater pre-treatment right amygdala activity with negative and positive condition in the risperidone group, and left amygdala activity with positive condition in divalproex group, predicted poor response on YMRS. Risperidone and divalproex yield differential patterns of prefrontal activity during an emotion processing task in pediatric mania. Increased amygdala activity at baseline is a potential biomarker predicting poor treatment response to both the risperidone and divalproex.

Double-blind randomized trial of risperidone versus divalproex in pediatric bipolar disorder.

OBJECTIVE: To determine the relative effects of risperidone and divalproex in pediatric mania. METHODS: This is a double-blind, randomized, outpatient clinical trial with 66 children and adolescents (mean age= 10.9 ± 3.3 years; age range= 8-18 years) with mania who were randomly assigned to either risperidone (0.5-2 mg/day, n= 33) or divalproex (60-120 µg/mL, n= 33) for a six-week period. Measures included the Young Mania Rating Scale (YMRS) and Child Depression Rating Scale-Revised (CDRS-R). RESULTS: Mixed-effects regression models, with interaction between time and the active drug as predictors, found that the risperidone group had more rapid improvement than the divalproex group (p < 0.05), although final scores did not differ significantly between groups. Mixed models using only those subjects who completed the six-week study found similar results. The response rate on YMRS was 78.1% for risperidone and 45.5% for divalproex (p < 0.01). The remission rate for risperidone was 62.5%, compared with 33.3% for divalproex (p < 0.05). Improvement on the CDRS-R was significantly higher for the risperidone group relative to the divalproex group (p < 0.05). There were no significant differences between groups in safety, but subject retention was significantly higher at study endpoint in the risperidone group (p < 0.01). Dropout rate was 24% in the risperidone group and 48% in the divalproex group, with increased irritability being the most common reason for dropout in the latter. There was no significant weight gain in either group. CONCLUSION: Results suggest that risperidone was associated with more rapid improvement and greater reduction in manic symptoms compared to divalproex. Although the results suggest that both drugs are safe, risperidone's lower attrition rate and lower rate of adverse events may suggest better toleration. Clinical trials with larger samples are required to confirm these preliminary findings.

Enhanced working and verbal memory after lamotrigine treatment in pediatric bipolar disorder.

OBJECTIVE: To examine the treatment impact of lamotrigine on the neurocognitive profile of patients with pediatric bipolar disorder (PBD). METHOD: Healthy controls (HC) (n = 24; mean age = 12.4 +/- 3.3 years) and unmedicated PBD patients with manic, mixed, or hypomanic episodes (n = 34; mean age = 13 +/- 3.1 years) were matched for IQ, age, sex, race, and socioeconomic status. A neurocognitive battery was administered at baseline and again after 14 weeks, during which PBD patients were treated with lamotrigine. RESULTS: Clinical symptoms improved with treatment in the patient group with significant change from baseline to follow-up on the Young Mania Rating Scale (p < 0.001) and the Children's Depression Rating Scale-Revised (p < 0.001). Global neurocognitive function improved with lamotrigine in PBD patients over time relative to that in HC, although overall performance remained impaired. Working memory and verbal memory significantly improved with treatment in patients, and deficits in these domains were no longer significantly impaired relative to HC at follow-up. Executive function significantly improved with treatment in the patient group but still lagged behind HC at follow-up. Performance on attention tests did not improve with treatment. CONCLUSIONS: There appears to be significant improvement in cognitive abilities in PBD patients treated with lamotrigine that is most prominent in the areas of working memory and verbal memory and that occurs along with mood stabilization.

Effectiveness of lamotrigine in maintaining symptom control in pediatric bipolar disorder.

OBJECTIVE: The aim of this study was to test the effectiveness and safety of lamotrigine in maintenance of manic and depressive symptom control in pediatric bipolar disorder (PBD). METHODS: A 14-week open trial was conducted with 46 subjects presenting with mania or hypomania. Lamotrigine was slowly titrated to a therapeutic dose over an 8-week period, during which acute symptoms were stabilized using second-generation antipsychotics (SGA), followed by a 6-week lamotrigine monotherapy phase. RESULTS: The response rate on manic symptoms (Young Mania Rating Score [YMRS] <12) was 72%, on depressive symptoms was 82% (Children's Depression Rating Scale-Revised [CDRS-R] <40), and the remission rate was 56% at the 14-week end point, on an average end-point lamotrigine dose of 1.8 mg/lb. There was further reduction in depressive symptoms during the lamotrigine maintenance phase. Benign rash was noted in 6.4% of patients. Out of half of the subjects who were in remission at 8 week, 3 subjects (23%) relapsed by week 14. CONCLUSION: Lamotrigine monotherapy appears to be effective in maintaining symptom control of manic and depressive symptoms in PBD and shows minimal adverse effects, although a future double-blind controlled trial is needed to confirm this finding. Portal of entry for lamotrigine treatment can be during acute illness and can sustain symptom control after establishing mood stabilization.

A one-year open-label trial of risperidone augmentation in lithium nonresponder youth with preschool-onset bipolar disorder.

OBJECTIVE: The aim of this study was to assess the safety and efficacy of risperidone augmentation of lithium in preschool-onset bipolar disorder (BD) among youth who insufficiently respond to lithium monotherapy. METHOD: Thirty-eight subjects between the ages of 4 and 17 years (mean age = 11.37 +/- 3.8 years) with onset of BD in preschool years (manic or mixed episode) entered this 12-month trial. All subjects received lithium monotherapy. Patients who failed to adequately respond to lithium monotherapy after 8 weeks and those who relapsed after an initial response were given risperidone augmentation for up to 11 months. The Young Mania Rating Scale (YMRS) was the primary outcome measure. Response was defined as a > or =50% decrease from baseline. Additional data were collected on diagnostic comorbidity, family history, number of hospitalizations, perinatal risk factors, history of physical or sexual abuse, Child Depression Rating Scale-Revised (CDRS-R), Clinical Global Impression (CGI) scale for BD (CGI-BP), Children's Global Assessment Scale (C-GAS), and adverse medication effects. RESULTS: Of the 38 subjects treated with lithium monotherapy, 17 responded, whereas 21 required augmentation with risperidone. Response rate in the youths treated with lithium + risperidone was 85.7% (n = 18/21). Significant predictors of inadequate response to lithium monotherapy requiring augmentation were: (1) attention-deficit/hyperactivity disorder (ADHD), (2) severity at baseline, (3) history of sexual or physical abuse, and (4) preschool age. Combination treatment of lithium and risperidone was found to be safe and well tolerated. CONCLUSIONS: A substantial proportion of youth with a history of preschool-onset BD treated with lithium were either nonresponders or partial responders. Subsequent augmentation of lithium with risperidone in these cases was well tolerated and efficacious. Potential predictors of lithium nonresponse identified in this study may guide the choice of medications earlier in the treatment process.

Child mania rating scale: development, reliability, and validity.

OBJECTIVE: To develop a reliable and valid parent-report screening instrument for mania, based on DSM-IVsymptoms. METHOD: A 21-item Child Mania Rating Scale-Parent version (CMRS-P) was completed by parents of 150 children (42.3% female) ages 10.3 +/- 2.9 years (healthy controls = 50; bipolar disorder = 50; attention-deficit/hyperactivity disorder [ADHD] = 50). The Washington University Schedule for Affective Disorders and Schizophrenia was used to determine DSM-IV diagnosis. The Young Mania Rating Scale, Schedule for Affective Disorders and Schizophrenia Mania Rating Scale, Child Behavior Checklist, and Child Depression Inventory were completed to estimate the construct validity of the measure. RESULTS: Exploratory and confirmatory factor analysis of the CMRS-P indicated that the scale was unidimensional. The internal consistency and retest reliability were both 0.96. Convergence of the CMRS-P with the Washington University Schedule for Affective Disorders and Schizophrenia mania module, the Schedule for Affective Disorders and Schizophrenia Mania Rating Scale, and the Young Mania Rating Scale was excellent (.78-.83). The scale did not correlate as strongly with the Conners parent-rated ADHD scale, the Child Behavior Checklist -Attention Problems and Aggressive Behavior subscales, or the child self-report Child Depression Inventory (.29-.51). Criterion validity was demonstrated in analysis of receiver operating characteristics curves, which showed excellent sensitivity and specificity in differentiating children with mania from either healthy controls or children with ADHD (areas under the curve of.91 to.96). CONCLUSION: The CMRS-P is a promising parent-report scale that can be used in screening for pediatric mania.

Divalproex sodium for pediatric mixed mania: a 6-month prospective trial.

OBJECTIVE: This prospective 6-month open trial examined the effectiveness and safety of divalproex sodium (DVPX) in pediatric mixed mania. METHOD: Thirty-four subjects with a mean age of 12.3 (SD = 3.7) years, DSM-IV diagnosis of a current mixed episode and a baseline Young Mania Rating Scale (YMRS) score >20 were treated with DVPX monotherapy. The primary outcome measures were the YMRS and the Child Depression Rating Scale-Revised. Secondary measures were the Clinical Global Impression Scale for Bipolar Disorder (CGI-BP) and the Children's Global Assessment of Functioning Scale (C-GAS). Measures of safety and tolerability were also administered. RESULTS: Effect size (Cohen's d) based on change scores from baseline was 2.9 for the YMRS and 1.23 for the CDRS-R. Response rate (> or =50% change from baseline YMRS score and < or =40 score on CDRS-R at the end of study) was 73.5%. The remission rate (> or =50% change from baseline on YMRS, < or =40 on CDRS-R, CGI-BP-Improvement subscale of < or =2, and > or =51 CGAS score) was 52.9%. Significant improvements (p < 0.001) from baseline were seen for mean scores on all outcome measures (i.e., YMRS, CGI-BP, CDRS-R, and C-GAS). DVPX was safe and well tolerated with no serious adverse events during the 6-month trial. CONCLUSION: This study provides evidence for the effectiveness and safety of DVPX in the treatment of pediatric mixed mania over a 6-month period. Placebo-controlled, randomized trials involving larger samples will ultimately shed light on the efficacy of this agent.

Open-label prospective trial of risperidone in combination with lithium or divalproex sodium in pediatric mania.

OBJECTIVE: This prospective 6-month open trial examined the safety and efficacy of two combination therapies for manic or mixed episodes of pediatric bipolar disorder: (1) divalproex sodium plus risperidone (DVPX+Risp), or (2) lithium plus risperidone (Li+Risp). METHODS: Thirty-seven (37) subjects aged 5 and 18 (age=12.1+/-3.5 years) with DSM IV current mixed or manic episode and Young Mania Rating Scale (YMRS) score >20 were sequentially assigned to either DVPX+Risp or Li+Risp in a 6-month, prospective open-label trial. Outcome measures included the YMRS, Clinical Global Impression Scale for Bipolar Disorder (CGI-BP), Child Depression Rating Scale-Revised (CDRS-R) as well as measures of safety and tolerability. RESULTS: Effect sizes (Cohen's d) based on change of YMRS scores from baseline were 4.36 for DVPX+Risp and 2.82 for Li+Risp. Response rates (>or=50% change from baseline YMRS score at the end of study) were 80% for DVPX+Risp and 82.4% for Li+Risp. Both combination treatments were well tolerated. Significant improvements (p<0.001) from baseline were seen for mean scores on all efficacy measures, i.e., YMRS, CGI-BP, and CDRS-R. There were no significant group differences in safety or tolerability, and no serious adverse events during the 6-month trial. CONCLUSION: Both DVPX+Risp and Li+Risp show strong effects coupled with safety and tolerability in treating children and adolescents with manic or mixed episodes associated with type I bipolar disorder.

A pharmacotherapy algorithm for stabilization and maintenance of pediatric bipolar disorder.

OBJECTIVE: To assess the feasibility and effectiveness of an evidence-based pharmacotherapy algorithm in the treatment of pediatric bipolar disorder. METHOD: The study reports the results of a study of 64 bipolar type I subjects who were treated according to an algorithm developed in our specialty clinic. All subjects had been diagnosed using the Washington University in St. Louis Schedule for Affective Disorders and Schizophrenia. Subjects scored an average of 28 (+/- 4) on the baseline Young Mania Rating Scale. All subjects were assessed over an 18-month period. In addition, we were able to match 17 of the 64 subjects in the algorithm sample for gender, age, ethnicity, socioeconomic status, and diagnosis with an equal number of subjects in a psychopharmacology clinic who received treatment as usual. RESULTS: Prescribing clinicians were able to implement primary and secondary strategies, including detailed tactics of medication choices in the algorithm group. Growth curve analysis of the total algorithm group showed strong and significant improvement in symptoms. Analyses of the matched groups also showed strong effects for the treatment algorithm over treatment as usual. Treatment adherence and family satisfaction were higher in the algorithm group. CONCLUSION: An evidence-based, problem-solving pharmacotherapy algorithm is feasible and may be associated with better outcomes in the treatment of pediatric bipolar disorder. Randomized trials will be necessary to gather additional support for the algorithm's effectiveness.

Child- and family-focused cognitive-behavioral therapy for pediatric bipolar disorder: development and preliminary results.

OBJECTIVE: To describe child- and family-focused cognitive-behavioral therapy (CFF-CBT), a new developmentally sensitive psychosocial intervention for pediatric bipolar disorder (PBD) that is intended for use along with medication. CFF-CBT integrates principles of family-focused therapy with those of CBT. The theoretical framework is based on (1). the specific problems of children and families coping with bipolar disorder, (2). a biological theory of excessive reactivity, and (3). the role of environmental stressors in outcome. CFF-CBT actively engages parents and children over 12 hour-long sessions. METHOD: An exploratory investigation was conducted to determine the feasibility of CFF-CBT. Participants included 34 patients with PBD (mean age 11.33 years, SD = 3.06) who were treated with CFF-CBT plus medication in a specialty clinic. Treatment integrity, adherence, and parent satisfaction were assessed. Symptom severity and functioning were evaluated before and after treatment using the severity scales of the Clinical Global Impression Scales for Bipolar Disorder (CGI-BP) and the Children's Global Assessment Scale (CGAS) respectively. RESULTS: On completion of therapy, patients with PBD showed significant reductions in severity scores on all CGI-BP scales and significantly higher CGAS scores compared to pretreatment results. High levels of treatment integrity, adherence, and satisfaction were achieved. CONCLUSIONS: CFF-CBT has a strong theoretical and conceptual foundation and represents a promising approach to the treatment of PBD. Preliminary results support the potential feasibility of the intervention.