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

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

Catatonia in autism: a distinct subtype?

Catatonia is a life-threatening disorder characterized by motor abnormalities, mutism, and disturbances of behaviour, which is increasingly being diagnosed in persons with autism. In this report, we describe the presentation and course of catatonia in an adolescent with autism who responded to electroconvulsive therapy (ECT). The illness started with depressive symptoms, but the predominant feature was one of extreme obsessive slowing and immobility. We propose that catatonia should be ruled out as a cause of regression sometimes seen in adolescents with autism, and that catatonia of autism may index a distinct subtype with a particularly poor outcome.

Autistic symptoms following herpes encephalitis.

Autism is a childhood onset neurodevelopmental disorder characterized by reciprocal social deficits, communication impairment, and rigid ritualistic interests, with the onset almost always before three years of age. Although the etiology of the disorder is strongly influenced by genes, environmental factors are also important. In this context, several reports have described its association with known medical conditions, including infections affecting the central nervous system. In this report, we describe an 11-year-old Asian youngster who developed the symptoms of autism following an episode of herpes encephalitis. In contrast to previous similar reports, imaging studies suggested a predominant involvement of the frontal lobes. At follow-up after three years, he continued to show the core deficits of autism. This case further supports the role of environmental factors, such as infections, in the etiology of autism, and suggests that in a minority of cases, autistic symptoms can develop in later childhood.

Myoclonus during prolonged treatment with sertraline in an adolescent patient.

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

Electroconvulsive therapy for minors: experiences and attitudes of child psychiatrists and psychologists.

OBJECTIVE: To estimate knowledge, experience, and attitudes towards the use of electroconvulsive treatment in minors (patients < 18 years of age), among child and adolescent psychiatrists and psychologists. METHOD: 1,600 questionnaires were mailed to a group of child and adolescent psychiatrists and psychologists. RESULT: There were 625 (39%) respondents. 329 (53.8%) of the respondents stated that they possessed minimal knowledge about the use of ECT in children and adolescents. Lack of confidence in providing a second opinion was common and reported by 75%. Compared with those with minimal knowledge, respondents with advanced knowledge reported a higher perception of safety and efficacy. The majority (70%) of the respondents regarded ECT as a treatment of last resort. CONCLUSION: Many child and adolescent psychiatrists and psychologists have very little knowledge, training, or experience in this treatment. They seem to be ill equipped to appropriately consider or advise patients and families about ECT. Clinical and research implications of these findings are discussed.

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

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

Anxiety contributes to suicidality in depressed adolescents.

Several studies have suggested a positive association between anxiety symptoms and suicidality in adults. However, relatively little is known about this topic in adolescents. To investigate this issue, we examined a group of adolescents admitted to our psychiatric inpatient unit. Fifty-six adolescents (mean age = 14.8 +/- 1.4; females = 34, males = 22; race = 95% Caucasians) participated in the study. Diagnoses were made using the DSM-III-R criteria and a diagnostic interview. Anxiety was found to significantly correlate with depression (r = .60; P = < .05) and suicidality (r = .72; P < .05). A multiple regression analysis revealed that anxiety and depression together accounted for more than half (55%) of the variance in suicidal ideation [F(2,46) = 28.4; P < .0001]. In addition, anxiety had an independent ability to predict suicidality (t = 5.01; P < .0001). Self-rated but not clinician-rated suicidality was positively correlated with both anxiety and depression. Clinical and research implications of these findings are discussed.

Aggressive behavior in clinically depressed adolescents.

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

Cognitive side effects of electroconvulsive therapy in adolescents.

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

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

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

Medication noncompliance in adolescents with psychiatric disorders.

The purpose of the study was to estimate prevalence of medication noncompliance among adolescents, following discharge from hospital. A second purpose was to identify predictors of such noncompliance. Seventy-one adolescents, who had been prescribed a medication during psychiatric hospitalization, were interviewed by telephone, 6-8 months post-hospitalization. Medication noncompliance was defined as discontinuing medication without the recommendation of the treating physician. Twenty-four subjects (33.8%) were noncompliant with medication. Age, race, gender, SES, diagnosis, type and number of medications, severity of depression, and family living arrangement did not predict noncompliance. We concluded that noncompliance with psychotropic medications was relatively common and difficult to predict in adolescents who had been hospitalized to a psychiatric inpatient unit; the majority of them suffered from depression. Clinicians should be aware that medication noncompliance may be common and a relatively unpredictable phenomenon.

Comorbidity of Asperger syndrome: a preliminary report.

Asperger syndrome (AS) is a pervasive developmental disorder characterized by autistic social dysfunction and idiosyncratic interests in the presence of normal intelligence. There is no history of language delay. Although people with AS are known to suffer from comorbid psychiatric conditions, few studies have systematically addressed this topic. This preliminary report describes the occurrence of psychiatric disorders in a series of patients with AS diagnosed according to the ICD-10/DSM-IV criteria. Out of 35 patients (29 males and six females; mean age 15.1 years; mean verbal IQ 105.9; mean performance IQ 97.5; mean full-scale IQ 102.7), 23 patients (65%) presented with symptoms of an additional psychiatric disorder at the time of evaluation or during the 2-year follow-up. Children were most likely to suffer from attention deficit hyperactivity disorder, while depression was the most common diagnosis in adolescents and adults. The implications of these findings are discussed.

Prediction of positive outcomes for adolescent psychiatric inpatients.

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

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

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

Psychotic versus nonpsychotic depression in hospitalized adolescents.

One hundred fifty adolescent inpatients with major depression were systematically assessed for demographic and clinical differences between psychotic and nonpsychotic depression. Delusions and/or hallucinations were present in 10% of the subjects. The psychotic group had significantly more frequent and severe suicidal ideation. Posttraumatic stress disorder was also more frequent in the psychotic group.

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

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

Predictors of comorbid alcohol and substance abuse in depressed adolescents.

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

Adolescent attitudes about death in relation to suicidality.

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