Remote assessment of ADHD in children and adolescents: recommendations from the European ADHD Guidelines Group following the clinical experience during the COVID-19 pandemic.

The COVID-19 pandemic led ADHD services to modify the clinical practice to reduce in-person contact as much as possible to minimise viral spread. This had far-reaching effects on day-to-day clinical practice as remote assessments were widely adopted. Despite the attenuation of the acute threat from COVID, many clinical services are retaining some remote practices. The lack of clear evidence-based guidance about the most appropriate way to conduct remote assessments meant that these changes were typically implemented in a localised, ad hoc, and un-coordinated way. Here, the European ADHD Guidelines Group (EAGG) discusses the strengths and weaknesses of remote assessment methods of children and adolescents with ADHD in a narrative review based on available data and expert opinions to highlight key recommendations for future studies and clinical practice. We conclude that going forward, despite remote working in clinical services functioning adequately during the pandemic, all required components of ADHD assessment should still be completed following national/international guidelines; however, the process may need adaptation. Social restrictions, including changes in education provision, can either mask or exacerbate features associated with ADHD and therefore assessment should carefully chart symptom profile and impairment prior to, as well as during an ongoing pandemic. While remote assessments are valuable in allowing clinical services to continue despite restrictions and may have benefits for routine care in the post-pandemic world, particular attention must be paid to those who may be at high risk but not be able to use/access remote technologies and prioritize these groups for conventional face-to-face assessments.

Validation of a Spanish-language version of the ADHD Rating Scale IV in a Spanish sample. / Validación de la versión en español de la escala de evaluación del trastorno por déficit de atención e hiperactividad (ADHD-RS-IV.es) en una muestra española.

OBJECTIVES: The purpose of this study is to validate a Spanish-language version of the 18-item ADHD Rating Scale-IV (ADHD-RS-IV.es) in a Spanish sample. METHODS: From a total sample of 652 children and adolescents aged 6 to 17 years (mean age was 11.14±3.27), we included 518 who met the DSM-IV-TR criteria for ADHD and 134 healthy controls. To evaluate the factorial structure, validity, and reliability of the scale, we performed a confirmatory factor analysis (CFA) using structural equation modelling on a polychoric correlation matrix and maximum likelihood estimation. The scale's discriminant validity and predictive value were estimated using ROC (receiver operating characteristics) curve analysis. RESULTS: Both the full scale and the subscales of the Spanish-language version of the ADHD-RS-IV showed good internal consistency. Cronbach's alpha was 0.94 for the full scale and ≥ 0.90 for the subscales, and ordinal alpha was 0.95 and ≥ 0.90, respectively. CFA showed that a two-factor model (inattention and hyperactivity/impulsivity) provided the best fit for the data. ADHD-RS-IV.es offered good discriminant ability to distinguish between patients with ADHD and controls (AUC=0.97). CONCLUSIONS: The two-factor structure of the Spanish-language version of the ADHD-RS-IV (ADHD-RS-IV.es) is consistent with those of the DSM-IV-TR and DSM-5 as well as with the model proposed by the author of the original scale. Furthermore, it has good discriminant ability. ADHD-RS-IV.es is therefore a valid and reliable tool for determining presence and severity of ADHD symptoms in the Spanish population.

[Genetic bases of attention deficit hyperactivity disorder]. / Bases geneticas del trastorno por deficit de atencion/hiperactividad.

AIMS: The purpose of this study is to update the information available on the main group of genes that have been related with a susceptibility to attention deficit hyperactivity disorder (ADHD) or with the pharmacological response to different drugs used in the treatment of ADHD, in a number of different association and meta-analysis studies. DEVELOPMENT: Different studies have provided evidence of the importance of the genetic load in the susceptibility to ADHD. The work carried out to date point to genes in the dopaminergic system, such as the gene that codes for the dopamine transporter (DAT1 or SLC6A3) and for the dopamine receptor D4 (DRD4); in the noradrenergic system, like the gene coding for the adrenergic alpha-2A receptor (ADRA2A), the COMT gene, which codes for the enzyme catechol-O-methyltransferase and the gene that codes for latrophilin 3 (LPHN3), as genes that are candidates for playing a part in the susceptibility to ADHD, and being involved in the pharmacological response as well as in the risk of presenting associated behavioural disorders. On the other hand, the genes involved in regulating the metabolism of the drugs used in the treatment of ADHD, such as the gene CYP2D6 and gene CES1, play a role in the efficiency and tolerance of these psycho-pharmaceuticals. CONCLUSIONS: Although in recent years there has been an increase in the number of pharmacogenetic studies conducted on ADHD, findings differ significantly from one study to another. Integrating and meta-analytical studies are needed to be able to develop a more personalised treatment for ADHD.

Insight correlates in child- and adolescent-onset first episodes of psychosis: results from the CAFEPS study.

BACKGROUND: The correlates of insight in early-onset psychosis have received little previous attention. METHOD: We studied clinical correlates of insight in a sample of 110 adolescent recent-onset psychosis patients (mean age 15.53 years; psychotic symptoms present for <6 months). Insight was measured with the Scale to Assess Unawareness of Mental Disorder (SUMD) at baseline, 6 months and 12 months follow-up. RESULTS: Insight improved over the early phases of the illness, in parallel with psychopathological improvement. Poor insight at baseline and 6 months correlated with poor functioning at 6 and 12 months respectively. Schizophrenia patients had poorer insight than patients with bipolar disorder at 6 and 12 months but not at baseline. Logistic and linear regressions were used to predict 12-month diagnoses and functioning based on insight measurements. Baseline awareness of illness was a significant predictor for diagnosis [odds ratio (OR) 1.4, 95% confidence interval (CI) 1.05-1.97]. Treatment compliance at 6 months did not correlate with baseline SUMD subscores, but correlated with insight into having a disorder (Spearman's rho=0.21, p=0.039), its consequences (Spearman's rho=0.28, p=0.006) and the need for treatment (Spearman's rho=0.26, p=0.012) at 6 months. The 'attribution of symptoms' dimension of insight is poorly correlated with other insight dimensions and with other clinical variables. CONCLUSIONS: Poor insight correlates with symptom severity and global functioning but also has some trait value for schizophrenia, which is apparent once acute psychotic symptomatology is not prominent. A multi-dimensional approach to the assessment of insight is necessary, as different dimensions are influenced by different factors.

[Attention deficit/hyperactivity disorder: burden of the disease according to subtypes in recently diagnosed children]. / Trastorno por déficit de atención/hiperactividad: impacto de la enfermedad de acuerdo al subtipo en niños con diagnóstico reciente.

INTRODUCTION: Attention-Deficit/Hyperactivity Disorder (ADHD) is associated with deterioration of several dimensions of quality of life (QoL) and with the development of comorbid psychiatric disorders. The objective of the present study is to evaluate the burden of illness of ADHD subtypes in untreated newly diagnosed children in Spain. METHODS: We recruited 124 children (80 combined, 25 inattentive and 19 hyperactive-impulsive subtype) aged 6-12 years with untreated newly diagnosed Diagnostic and Statistical Manual of Mental Disorders, 4th edition DSM-IV) ADHD. We collected socio-demographic, clinical (Attention-Deficit/Hyperactivity Disorder Rating Scale ADHD-RS], Conner's Parent Rating Scale-Revised: Short Form [CPRS:R-S], Clinical Global Impression-Severity [CGI-S], Kiddie Schedule for Affective Disorders and Schizophrenia for School Aged Children-Present and Lifetime Version [K-SADS-PL], intelligence Quotient [IQ]), Quality of Life (QoL), Child Health Questionnaire-Parent Form 50 CHQ-PF50), academic performance and health care resources utilization data. We investigated the correlations between ADHD symptom severity and QoL, academic performance and time from onset of symptoms to diagnosis. RESULTS: QoL of children with combined-type ADHD was rated as significantly worse in patients with predominance of hyperactivity/impulsivity for most of the domains. Inattentive-type children also had worse ratings than patients with hyperactivity/impulsivity predominance in most of the domains. The ADHD Index of Conner's Parent Rating Scale-Revised: Short Form (CPRS-R:S) was significantly lower in hyperactive/impulsive patients. We found no differences across subtypes in IQ, academic performance and health care resources utilization. Higher ADHD symptom severity was associated to poor QoL. CONCLUSIONS: Combined and inattentive subtypes are associated with greater disorder severity, more comorbid psychiatric disorders, and worse QoL than the subtype with hyperactivity/impulsivity predominance.

Trastorno por déficit de atención/hiperactividad: impacto de la enfermedad de acuerdo al subtipo en niños con diagnóstico reciente / Attention deficit/hyperactivity disorder: burden of the disease according to subtypes in recently diagnosed children

Introducción. El trastorno por déficit de atención/hiperactividad (TDAH) se asocia con un deterioro en varias dimensiones de calidad de vida (QoL) y el desarrollo de trastornos psiquiátricos comórbidos. El objetivo del presente estudio es evaluar el impacto de la enfermedad de los subtipos de TDAH en niños con diagnóstico inicial y sin tratamiento en España. Métodos. Reclutamos a 124 niños (80 de subtipo combinado, 25 inatento y 19 hiperactividad-impulsividad) entre 6 y 12 años de edad con nuevo diagnóstico de TDAH (Manual diagnóstico y estadístico de los trastornos mentales, 4.a ed., DSM-IV) y sin tratar. Recogimos datos sociodemográficos y clínicos (Attention Deficit/Hyperactivity Disorder-Rating Scale [Escala de evaluación para el trastorno por déficit de atención/hiperactividad, ADHD-RS], Conner’s Parent Rating Scale-Revised: Short Form [Escala de evaluación de Conner, versión para los padres revisada: versión breve, CPRS:R-S], Impresión Clínica Global-Severidad [ICG-S], Kiddie Schedule of Affective Disorders and Schizophrenia for School Aged Children-Present and Lifetie Version [Inventario Kiddie para los trastornos afectivos esquizofrenia para niños en edad escolar, versión actual y a lo largo de la vida, K-SADS-PL] y coeficiente intelectual [CI]), de Qualite of Life (Calidad de vida, Qol), Child Health Questionnaire-Parent Form 50 (Cuestionario de Salud Infantil, versión para los padres de 50 ítems, CHQ-PF50), rendimiento académico y utilización de recursos sanitarios. Investigamos las correlaciones entre la gravedad del TDAH y QoL, rendimiento académico y tiempo transcurrido desde el inicio de los síntomas hasta el diagnóstico. Resultados. La QoL de niños con subtipo combinado de TDAH se valoró como significativamente peor que en pacientes con predominio de hiperactividad/impulsividad en la mayoría de los dominios. Los niños con subtipo inatento también puntuaron peor que los de predominio de hiperactividad/impulsividad en varios dominios. La puntuación de ADHD de la CPRS-R:S fue significativamente menor en los pacientes con predominio de hiperactividad/impulsividad. No encontramos diferencias entre los distintos subtipos respecto al CI, rendimiento académico y utilización de recursos sanitarios. Una mayor gravedad de los síntomas del TDAH se asoció con una peor QoL. Conclusiones. Los subtipos combinado e inatento se asociaron con mayor gravedad del trastorno, más trastornos psiquiátricos comorbidos y peor QoL que el subtipo con predominio de hiperactividad/impulsividad (AU)

Introduction. Attention-Deficit/Hyperactivity Disorder (ADHD) is associated with deterioration of several dimensions of quality of life (QoL) and with the development of comorbid psychiatric disorders. The objective of the present study is to evaluate the burden of illness of ADHD subtypes in untreated newly diagnosed children in Spain. Methods. We recruited 124 children (80 combined, 25 inattentive and 19 hyperactive-impulsive subtype) aged6-12 years with untreated newly diagnosed Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-IV) ADHD. We collected socio-demographic, clinical(Attention-Deficit/Hyperactivity Disorder Rating Scale[ADHD-RS], Conner’s Parent Rating Scale-Revised: Short Form [CPRS:R-S], Clinical Global Impression-Severity [CGI-S], Kiddie Schedule for Affective Disorders and Schizophrenia for School Aged Children-Present and Lifetime Version[K-SADS-PL], intelligence Quotient [IQ]), Quality of Life (QoL), Child Health Questionnaire-Parent Form 50(CHQ-PF50), academic performance and health care resources utilization data. We investigated the correlations between ADHD symptom severity and QoL, academic performance and time from onset of symptoms to diagnosis. Results. QoL of children with combined-type ADHD was rated as significantly worse in patients with predominance of hyperactivivity/impulsivity for most of the domains. Inattentive-type children also had worse ratings than patients with hyperactivity/impulsivity predominance in most of the domains. The ADHD Index of Conner’s Parent Rating Scale-Revised: Short Form (CPRS-R:S) was significantly lower in hyperactive/impulsive patients. We found no differences across subtypes in IQ, academic performance and health care resources utilization. Higher ADHD symptom severity was associated to poor QoL. Conclusions. Combined and inattentive subtypes are associated with greater disorder severity, more comorbid psychiatric disorders, and worse QoL than the subtype with hyperactivity/impulsivity predominance (AU)

Perseverative error in schizophrenia: correlation with cortical blood flow by SPECT.

INTRODUCTION: Perseverative error (PE) is a core symptom of schizophrenia which has been proposed as a phenotypic marker of the illness. Moreover, hypofrontality observed in functional neuroimaging studies while executing a cognitive task has also been suggested as a characteristic sign of schizophrenia. We propose combining symptom and sign to demonstrate the existence of a regional cortical blood flow (RCBF) pattern associated to PE that might constitute a biological marker of schizophrenia. MATERIAL AND METHOD: We used Single Photon Emission Computerized Tomography (SPECT), to study the RCBF associated to PE and to correct response (CR), during the execution of the Wisconsin Card Sorting Test (WCST), of 18 patients with schizophrenia and 13 controls. We focused on five well-defined bilateral brain regions, using the RCBF of the same regions at rest as a baseline. RESULTS: Patients made more PE than controls in the WCST. Among patients, we observed a correlation between PEs and right occipital RCBF. Among controls, we found a negative correlation between PEs and left temporal cortex RCBF and a positive correlation between CRs and left frontobasal and overall left frontal cortexes RCBF. CONCLUSIONS: The severity of PE is associated to higher right parietal-occipital activity in patients with schizophrenia. CR in the WCST are associated to higher left frontal activity in controls but not in patients. Probably, there is a RCBF redistribution pattern related to the typical perseveration of schizophrenia which might constitute a phenotypic marker of the illness observable by functional neuroimaging techniques.

Estudio del flujo sanguíneo cerebral regional (FSCr) mediante SPECT, en reposo y activación con el test de Clasificación de Tarjetas de Wisconsin (WCST), en pacientes con esquizofrenia sin tratamiento o tratados con neurolépticos atípicos / Regional cerebral blood flow SECT study, at rest and during Wisconsin Card Sorting Test (WCST) performance, in schizophrenia naive patients or treated with atypical neuroleptics

Introducción. Corroborar la hipótesis de la hipofrontalidad en la esquizofrenia y estudiar la posible relación existente entre los síntomas positivos y negativos (medidos con la Escala de síndromes positivos y negativos, PANSS) y el flujo sanguíneo cerebral regional (FSCr), tanto en reposo como en activación mediante el Wisconsin Card Sorting Test (WCST). Métodos. Comparamos el FSCr de un grupo de controles (n = 18) con el de un grupo de pacientes con esquizofrenia (n = 21) mediante tomografía computarizada por emisión de fotón único (SPECT). Resultados. En el grupo control los índices de FSC frontal izquierdo en reposo y activación y derecho en activación son significativamente superiores a los de los pacientes. Únicamente en los controles el índice frontal derecho experimenta un incremento significativo como resultado de la activación. El FSC occipital derecho en activación se incrementa significativamente sólo en los pacientes. Observamos una correlación positiva significativa entre las puntuaciones de la PANSS-P y el índice frontal izquierdo en reposo. Síntomas aislados de la PANSS-N como dificultad en el pensamiento abstracto (N5) y falta de espontaneidad y fluidez en la conversación (N6) se asocian a hipoperfusión frontal en reposo. El embotamiento afectivo (N1) se asocia a hipoperfusión frontal izquierda en activación. Conclusiones. Nuestros datos apoyan la hipótesis de la hipofrontalidad, tanto en reposo como en activación, es decir, entendida como la incapacidad de los pacientes con esquizofrenia para incrementar el FSC frontal durante la ejecución del WCST (activación). Los síntomas positivos de la esquizofrenia se asocian a hiperperfusión frontal izquierda

Introduction. To corroborate the hypothesis of hypofrontality in schizophrenia and to study the relationship between positive/negative symptoms (measured by the positive and negative syndrome scale [PANSS]) and regional cortical blood flow (rCBF), both at rest and during the Wisconsin Card Sorting Test (WCST) performance (activation). Methods. We compared a control group (n = 18) to a group of patients with schizophrenia (n = 21) in terms of rCBF, measured by single photon emission computed tomography (SPECT). Results. We found significantly higher left-frontal- CBF (during the WCST performance and at rest) and right-frontal-CBF (only at rest) in control subjects. Only the control group showed a right-frontal-CBF increase during activation. Only the patients group showed a significant right-occipital-CBF increase during the activation. We observed a positive significant correlation between the PANSS-P score and the left- frontal index at rest. Some negative symptoms such as difficulty in abstract thinking (N5) and lack of spontaneity and flow of conversation (N6) are associated to low frontal blood flow at rest. Affective blunting (N1) is associated to low left-frontal blood flow during activation. Conclusions. Our data support the hypothesis of hypofrontality, at rest and during activation, which means the incapacity of schizophrenic patients to increase the frontal CBF while performing the WCST (activation). Schizophrenia positive symptoms are associated to high left-frontal blood flow

Regional cerebral blood flow SPECT study, at rest and during Wisconsin Card Sorting Test (WCST) performance, in schizophrenia naive patients or treated with atypical neuroleptics.

INTRODUCTION: To corroborate the hypothesis of hypofrontality in schizophrenia and to study the relationship between positive/negative symptoms (measured by the positive and negative syndrome scale [PANSS]) and regional cortical blood flow (rCBF), both at rest and during the Wisconsin Card Sorting Test (WCST) performance (activation). METHODS: We compared a control group (n = 18) to a group of patients with schizophrenia (n = 21) in terms of rCBF, measured by single photon emission computed tomography (SPECT). RESULTS: We found significantly higher left-frontal- CBF (during the WCST performance and at rest) and right-frontal-CBF (only at rest) in control subjects. Only the control group showed a right-frontal-CBF increase during activation. Only the patients group showed a significant right-occipital-CBF increase during the activation. We observed a positive significant correlation between the PANSS-P score and the left- frontal index at rest. Some negative symptoms such as difficulty in abstract thinking (N5) and lack of spontaneity and flow of conversation (N6) are associated to low frontal blood flow at rest. Affective blunting (N1) is associated to low left-frontal blood flow during activation. CONCLUSIONS: Our data support the hypothesis of hypofrontality, at rest and during activation, which means the incapacity of schizophrenic patients to increase the frontal CBF while performing the WCST (activation). Schizophrenia positive symptoms are associated to high left-frontal blood flow.

Avances de la investigación biológica en la esquizofrenia: aportaciones de neuroimagen funcional / No disponible

Se revisan logros de los estudios histológicos que, junto a los hallazgos de la incipiente aplicación de la neuroimagen, han revelado algunos mecanismos implicados en la etiopatogenia y fisiopatología de la esquizofrenia. Desde hace pocos años, la confluencia de las diferenteslíneas de investigación han producido importantes avancesque marcaran la trayectoria futura de la investigación biológica de la esquizofrenia en psiquiatría, y se han publicado los primeros estudios que relacionan la influencia que ejercen determinados genotipos de genes candidatos, sobre las alteraciones neurofisiológicas, ejecución de test de memoria de trabajo, variaciones estructurales y funcionales y psicopatológicas en pacientes con esquizofrenia, individuos de alto riesgo y personas sanas. En definitiva, estudios que detectan los individuos más vulnerables al padecimiento de este gravetrastorno mental

In this article we review the most recent studies in neuroimage that have helped to understand the etiology and pathogenesis of schizophrenia. In the last few years different research lines came together to produce importand advances and open new pathways for the futureknowledge about schizophrenia. The first studies on the different genotipes involved in schizophrenia were published and also studies on neurophysiology, neuropsychology, structural and functional neuroimage in patients with schizophrenia, persons at high risk fordeveloping the illness, and healthy controls have been developed. In summary, in the last years we have many available studies on different fields that help to understand the etiology and pathology of schizophrenia,and different characteristics in high risk individuals

[Atomoxetine safety and efficacy in children with attention deficit/hyperactivity disorder (ADHD): initial phase of 10-week treatment in a relapse prevention study with a Spanish sample]. / Seguridad y eficacia de la atomoxetina en niños con trastorno por déficit de atención/hiperactividad (TDAH): fase inicial durante 10 semanas en estudio de prevención de recaídas en una muestra española.

INTRODUCTION: Attention-deficit/hyperactivity disorder (ADHD) appears to be associated to problems with regulation of cortical dopaminergic/noradrenergic function. The purpose of this work is to present efficacy and safety data from 10-week open label treatment with atomoxetine, a highly selective norepinephrine reuptake inhibitor, in a Spanish sample of children and adolescents with ADHD participating in a double-blinded, placebo-controlled, multinational study on relapse prevention. PATIENTS AND METHODS: Sub-analysis of data in 36 children and adolescents aged 6 to 15 years, with diagnosis of ADHD (DSM-IV) included in Spain, receiving open-label treatment with atomoxetine for 10 weeks and assessed using ADHD-RS, CGI-ADHD-S, CPRS-R:S, CTRS-R:S y CHQ-PF50. RESULTS: After 10 weeks of treatment with atomoxetine, statistically significant reductions in ADHD-RS, CGI-ADHD-S, CPRS-R:S and CTRS-R:S scores were obtained in both subtypes; 87.5 % of inattentive patients and 82.14 % of patients with combined subtype were responders. No recurrences were observed. No serious adverse event-driven discontinuations occurred, and no statistically significant changes in blood pressure, but a mild increase in heart rate (p < 0.0001) were observed. CONCLUSIONS: In general, atomoxetine was well tolerated and effective in the open phase in Spanish patients, both for inattentive and combined subtypes. Atomoxetine appears as a non-stimulant therapeutic alternative for the treatment of ADHD.

Seguridad y eficacia de la atomoxetina en niños con trastorno por déficit de atención/hiperactividad (TDAH): fase inicial durante 10 semanas en estudio de prevención de recaídas en una muestra española / Atomoxetine safety and efficacy in children with attention deficit/hyperactivity disorder (ADHD): initial phase of 10-week treatment in a relapse prevention study with a Spanish sample

Introducción. El trastorno por déficit de atención/hiperactividad (TDAH) parece estar asociado con problemas de regulación de la función dopaminérgica/noradrenérgica cortical. El propósito del presente trabajo es presentar los datos de eficacia y seguridad del tratamiento abierto durante 10 semanas con atomoxetina, un inhibidor altamente específico de la recaptación de noradrenalina, en una muestra española de niños y adolescentes con TDAH que participan en un estudio multinacional, doble ciego, controlado con placebo de prevención de recaídas. Pacientes y métodos. Subanálisis de los datos de 36 niños y adolescentes de 6 a 15 años diagnosticados de TDAH (DSM-IV) incluidos en España tratados durante 10 semanas de forma abierta con atomoxetina y valorados mediante las escalas ADHD-RS, CGI-ADHD-S, CPRS-R:S, CTRS-R:S y CHQ-PF50. Resultados. Tras 10 semanas de tratamiento con atomoxetina se produjo una reducción estadísticamente significativa en las escalas ADHD-RS, CGI-ADHD-S, CPRS-R:S y CTRS-R:S en ambos subtipos, respondiendo el 87,5 % de los pacientes del subtipo déficit de atención y el 82,14 % de los pacientes del subtipo combinado. No se produjeron recaídas. No se produjeron abandonos debidos a acontecimientos adversos graves ni se detectaron cambios estadísticamente significativos en la presión arterial, aunque sí un ligero aumento en la frecuencia cardíaca (p < 0,0001). Conclusiones. En general, atomoxetina fue bien tolerada y se mostró efectiva en la fase abierta en los pacientes de la muestra española, tanto en el subtipo déficit de atención como combinado. La atomoxetina parece mostrarse como una alternativa terapéutica no estimulante para el tratamiento de la TDAH

Introduction. Attention-deficit/hyperactivity disorder (ADHD) appears to be associated to problems with regulation of cortical dopaminergic/noradrenergic function. The purpose of this work is to present efficacy and safety data from 10-week open label treatment with atomoxetine, a highly selective norepinephrine reuptake inhibitor, in a Spanish sample of children and adolescents with ADHD participating in a double-blinded, placebo-controlled, multinational study on relapse prevention. Patients and methods. Sub-analysis of data in 36 children and adolescents aged 6 to 15 years, with diagnosis of ADHD (DSM-IV) included in Spain, receiving open-label treatment with atomoxetine for 10 weeks and assessed using ADHD-RS, CGI-ADHD-S, CPRS-R:S, CTRS-R:S y CHQ-PF50. Results. After 10 weeks of treatment with atomoxetine, statistically significant reductions in ADHD-RS, CGI-ADHD-S, CPRS-R:S and CTRS-R:S scores were obtained in both subtypes; 87.5 % of inattentive patients and 82.14 % of patients with combined subtype were responders. No recurrences were observed. No serious adverse event-driven discontinuations occurred, and no statistically significant changes in blood pressure, but a mild increase in heart rate (p < 0.0001) were observed. Conclusions. In general, atomoxetine was well tolerated and effective in the open phase in Spanish patients, both for inattentive and combined subtypes. Atomoxetine appearsas a non-stimulant therapeutic alternative for the treatment of ADHD

Prior stimulant treatment in adolescents with bipolar disorder: association with age at onset.

OBJECTIVES: To compare demographic and clinical characteristics between bipolar adolescents with and without a history of stimulant treatment, we hypothesized that adolescents treated with stimulants would have an earlier age at onset of bipolar disorder, independent of co-occurring attention-deficit-hyperactivity disorder (ADHD). METHOD: Thirty-four adolescents hospitalized with mania were assessed using the Washington University at St Louis Kiddie Schedule for Affective Disorders and Schizophrenia (WASH-U-KSADS). We systematically evaluated age at onset of bipolar disorder and pharmacological treatment history. RESULTS: Bipolar adolescents with a history of stimulant exposure prior to the onset of bipolar disorder had an earlier age at onset of bipolar disorder than those without prior stimulant exposure. Additionally, bipolar adolescents treated with at least two stimulant medications had a younger age at onset compared with those who were treated with one stimulant. There was no difference in age at onset of bipolar disorder between bipolar adolescents with and without ADHD. CONCLUSIONS: Our results suggest that stimulant treatment, independent of ADHD, is associated with younger age at onset of bipolar disorder. A behavioral sensitization model is proposed to explain our findings. There are several limitations to our study including the small sample size, the retrospective assessment of stimulant exposure and age at onset of bipolar disorder, and the inclusion of only hospitalized patients, who may be more likely to present with a severe illness. Nonetheless, future prospective longitudinal investigations that systematically assess the effects of stimulant medications in children with or at genetic risk for bipolar disorder are warranted.

Effects of race on psychiatric diagnosis of hospitalized adolescents: a retrospective chart review.

BACKGROUND: Several studies have reported that patient ethnicity influences psychiatric diagnosis, although this has only been examined in adolescents in two prior studies. One study was based on an outpatient sample and the other was a retrospective study involving a relatively small sample of inpatients. We hypothesized that, as reported in adults, African American adolescents would be diagnosed with schizophrenic spectrum disorders more frequently than Caucasians, and Caucasians correspondingly would receive more affective disorders diagnoses. METHODS: We retrospectively examined the charts of all adolescents (ages 12-18 years) admitted to the Adolescent Psychiatry Unit at Cincinnati Children's Hospital Medical Center (n = 1,001) between July 1995 and June 1998 for demographic information and discharge diagnoses. We used insurance status as a proxy for socioeconomic status. RESULTS: African American males were more commonly diagnosed with schizophrenic spectrum disorders than were African American women, Caucasian women, and Caucasian men. There were significantly more African Americans diagnosed with conduct disorder than Caucasians. In contrast, Caucasians were diagnosed with alcohol use disorders and major depression more often. CONCLUSIONS: Patient race and sex may influence clinical psychiatric diagnoses of hospitalized adolescents. Further investigations using structured interviews are necessary to determine whether the disparity in clinical diagnosis is secondary to actual gender and racial differences in the rates of illnesses in hospitalized adolescents or due to other factors that may contribute to diagnostic practices.

Divalproex sodium in sex offenders with bipolar disorders and comorbid paraphilias: an open retrospective study.

BACKGROUND: This study evaluated divalproex response in sex offenders with a bipolar disorder. METHODS: We reviewed the records of all sex offenders who participated in a residential rehabilitative program who received divalproex for treatment of a bipolar disorder. Patients' mood symptoms and, when present, comorbid paraphilic symptoms, were retrospectively assessed using the CGI severity scale. RESULTS: Sex offenders displayed significant improvement in manic symptoms with divalproex treatment. However, there was no significant improvement in paraphilic symptoms in the subset of patients admitting to these symptoms. CONCLUSION: Divalproex may be effective for manic symptoms in sex offenders with a bipolar disorder. However, for bipolar sex offenders with comorbid paraphilias, the drug may not be effective for paraphilic symptoms. LIMITATIONS: This study was limited by its retrospective, open-label design, lack of systematic means of assessing manic and paraphilic symptoms, and small sample size. CLINICAL RELEVANCE: Divalproex may be a helpful adjunct in the treatment of the subset of sex offenders who have a bipolar disorder.

Reliability of the Washington University in St. Louis Kiddie Schedule for Affective Disorders and Schizophrenia (WASH-U-KSADS) mania and rapid cycling sections.

OBJECTIVE: To investigate the reliability of the Washington University in St. Louis Kiddie Schedule for Affective Disorders and Schizophrenia (WASH-U-KSADS) mania and rapid cycling sections. METHOD: The 1986 version of the KSADS was modified and expanded to include onset and offset of each symptom for both current and lifetime episodes, expanded prepubertal mania and rapid cycling sections, and categories for attention-deficit/hyperactivity disorder and other DSM-IV diagnoses. To optimize diagnostic research, skip-outs were minimized. Subjects participated in the ongoing "Phenomenology and Course of Pediatric Bipolar Disorder" study. Mothers and children were interviewed separately by research nurses who were blind to diagnostic group status. In addition, ratings of off-site child psychiatrists, made from the narrative documentation given for each WASH-U-KSADS item, were compared with research nurse ratings. This work was performed between 1995 and 2000. RESULTS: There was 100% interrater reliability, five consecutive times, as both interviewer and observer after 10 to 15 trials. The kappa values of comparisons between research nurse and off-site blind best-estimate ratings of mania and rapid cycling sections were excellent (0.74-1.00). High 6-month stability for mania diagnoses (85.7%) and for individual mania items and validity against parental and teacher reports were previously reported. CONCLUSIONS: The WASH-U-KSADS mania and rapid cycling sections have acceptable reliability.

Diagnostic characteristics of 93 cases of a prepubertal and early adolescent bipolar disorder phenotype by gender, puberty and comorbid attention deficit hyperactivity disorder.

OBJECTIVE: Etiopathogenetic and treatment studies require homogeneous phenotypes. Therefore, effects of gender, puberty, and comorbid attention deficit hyperactivity disorder (ADHD) on DSM-IV mania criteria and other characteristics of a prepubertal and early adolescent bipolar disorder (PEA-BP) phenotype were investigated. METHOD: Consecutively ascertained PEA-BP (with or without comorbid ADHD) outpatients (n = 93) were blindly assessed by research nurses with comprehensive instruments given to mothers and children separately, consensus conferences, and offsite blind best estimates of both diagnoses and mania items. To fit the study phenotype, subjects needed to have current DSM-IV mania or hypomania with elated mood and/or grandiosity as one criterion and to be definite cases by severity ratings. RESULTS: Subjects were aged 10.9 +/- 2.6 years, had current episode length of 3.6 +/- 2.5 years, and had early age of onset at 7.3 +/- 3.5 years. No significant differences were found by gender, puberty, or comorbid ADHD on rates of mania criteria (e.g., elation, grandiosity, racing thoughts), mixed mania, psychosis, rapid cycling, suicidality, or comorbid oppositional defiant disorder (ODD), with few exceptions. Subjects with comorbid ADHD were more likely to be younger and male. Pubertal subjects had higher rates of hypersexuality. CONCLUSIONS: These findings support that the PEA-BP phenotype is homogeneous except for differences (hyperactivity, hypersexuality) that mirror normal development.