Efficacy of paroxetine in the treatment of adolescent major depression: a randomized, controlled trial.

OBJECTIVE: To compare paroxetine with placebo and imipramine with placebo for the treatment of adolescent depression. METHOD: After a 7- to 14-day screening period, 275 adolescents with major depression began 8 weeks of double-blind paroxetine (20-40 mg), imipramine (gradual upward titration to 200-300 mg), or placebo. The two primary outcome measures were endpoint response (Hamilton Rating Scale for Depression [HAM-D] score < or = 8 or > or = 50% reduction in baseline HAM-D) and change from baseline HAM-D score. Other depression-related variables were (1) HAM-D depressed mood item; (2) depression item of the Schedule for Affective Disorders and Schizophrenia for Adolescents-Lifetime version (K-SADS-L); (3) Clinical Global Impression (CGI) improvement scores of 1 or 2; (4) nine-item depression subscale of K-SADS-L; and (5) mean CGI improvement scores. RESULTS: Paroxetine demonstrated significantly greater improvement compared with placebo in HAM-D total score < or = 8, HAM-D depressed mood item, K-SADS-L depressed mood item, and CGI score of 1 or 2. The response to imipramine was not significantly different from placebo for any measure. Neither paroxetine nor imipramine differed significantly from placebo on parent- or self-rating measures. Withdrawal rates for adverse effects were 9.7% and 6.9% for paroxetine and placebo, respectively. Of 31.5% of subjects stopping imipramine therapy because of adverse effects, nearly one third did so because of adverse cardiovascular effects. CONCLUSIONS: Paroxetine is generally well tolerated and effective for major depression in adolescents.

Adolescent depression: controlled desipramine treatment and atypical features.

The study was designed to test the efficacy of desipramine in adolescents with major depression (MDD). In addition, we assessed the presence of atypical features of MDD, consisting of mood reactivity and two of four associated features (rejection sensitivity, hyperphagia, hypersomnia, and leaden paralysis). Patients were randomized to desipramine (DMI) or placebo for 6 weeks, provided they failed to improve (e.g., meeting MDD criteria and a Hamilton Depression Scale score > or = 18) after 2 weeks on single blind placebo. Of 94 adolescents (ages 13-18) who were diagnosed as having MDD, 64 entered the study and 62 received placebo for 2 weeks. Of these, 45 were randomized to DMI or placebo. Completed analyses did not reveal significant improvement for the active treatment compared to the placebo. A large proportion of adolescents responded to placebo (50%), suggesting the need for very large samples to detect differential treatment efficacy, should it exist. A relatively high rate of atypical depression was observed (47% in the 64 patients entered). In view of the demonstrated specificity of monoamine oxidase inhibitor efficacy in adults with atypical features of MDD, this clinical subtype may have relevance to future investigation of therapeutic interventions in adolescent MDD.

Hospitalizing the suicidal adolescent: decision-making criteria of psychiatric residents.

OBJECTIVE: The primary purpose of this research is to investigate the criteria used by general psychiatric residents in determining the appropriateness of hospitalization. METHOD: A questionnaire containing 64 vignettes describing adolescent suicide attempts was completed by a sample of 33 residents from a general psychiatry training program. Six variables known to relate to lethality of attempt were systematically varied within the vignettes: gender, depression, conduct disorder/substance abuse, previous attempts, suicidal relative, and family supports. Respondents were asked to judge the appropriateness of hospitalization for each vignette. RESULTS: Hospitalization preference was significantly predicted by all risk factors except for gender, with the presence of depression emerging as the most important predictor of hospitalization. Residents recommended hospitalization more frequently than did experienced child and adolescent clinicians. In comparison with experienced clinicians, residents placed more importance on depression, and less importance on conduct disorder/substance abuse, in making decisions to hospitalize. CONCLUSIONS: Although psychiatric residents use known risk factors for adolescent suicide in assessing need for hospitalization, there was clear support for further training initiatives for psychiatric residents concerning the assessment of suicidal adolescents.

Sleep problems of elementary school children. A community survey.

OBJECTIVE: To examine the prevalence, co-occurrence, and correlates of sleep problems among elementary school children. DESIGN: Survey. SETTING: General community. PARTICIPANTS: The parents of 987 children aged 5 to 12 years completed an anonymous survey distributed in their children's schools. MAIN OUTCOME MEASURES: The survey form asked about background characteristics, children's sleep environment, sleep habits, adult interventions, sleep history, and specific sleep problems. RESULTS: Bedtime resistance was the most prevalent sleep problem (27%). Sleep-onset delays (11.3%), night waking (6.5%), morning wake-up problems (17%), and fatigue complaints (17%) were also common. Among children with sleep-onset problems, 80% displayed bedtime resistance, while 34% of bedtime resisters had onset problems. Onset problems correlated with more fears, night waking, psychiatric and medical conditions, the need for reassurance and caregiver proximity, and history of sleep problems. Bedtime resistance was associated with an inconsistent bedtime and falling asleep away from bed. Those who display delayed sleep onset and bedtime resistance also wake later, suggesting that sleep-phase delays may maintain these problems. CONCLUSIONS: The results confirm bedtime resistance as parents principal sleep-related complaint for this age group but reveal a subgroup more prone to insomnia, night waking, and anxiety-related features. Phase delay findings suggest the importance of limits around wake-up time as well as bedtime. The results highlight the importance of distinctly evaluating bedtime resistance, sleep onset, sleep maintenance, waking, and emotional adjustment.

Teacher ratings of hyperactivity, inattention, and conduct problems in preschoolers.

Age and sex norms of classroom behavior in preschoolers were established on a standard measure, the Revised Conners Teacher Rating Scale, and the utility of this measure for assessing problem behavior in preschoolers was examined. Teachers provided ratings for 455 nonreferred preschoolers. In addition, ratings were obtained for 12 clinically referred preschoolers diagnosed with attention deficit hyperactivity disorder. The Conduct Problems, Inattention, and Hyperactivity subscales, as well as the Hyperactivity Index, were found to have good internal reliability and were related to each other in predictable ways. Normative data are presented by age and sex. Age was inversely related to scores for the Conduct Problems subscale, the Hyperactivity subscale and the Index. Sex was a significant predictor of subscale scores, with boys receiving higher scores than girls. Subscale scores and nearly all item scores were highly significantly different between clinically referred and nonreferred preschoolers. The results provide a standard upon which to evaluate preschool-aged children in clinical and research settings.

Thought disorder in adolescent-onset schizophrenia.

The nature of the thinking disturbances found in adolescent-onset psychotic conditions is not as well-characterized as the thought disorders found in adult psychotic patients. We used the Thought Disorder Index to examine whether schizophrenic patients in whom psychotic symptoms appear in adolescence show the same characteristic features of thought disorder as do adult schizophrenics. Quantitative and qualitative features of thought disorder were assessed in psychiatric inpatients with adolescent-onset schizophrenia, psychotic depression, and nonpsychotic conditions compared with normal control adolescents. Elevated thought disorder occurred in all groups of adolescents hospitalized for an acute episode of psychiatric illness. The magnitude of the elevation and the frequency of occurrence of disordered thinking were greatest in the psychotic adolescents. The qualitative features of the thought disturbances found in the schizophrenic adolescents were distinct from those observed in adolescents with psychotic depression. The thinking of the schizophrenic adolescents resembled that of adult schizophrenics. In both conditions thought disorder is characterized by idiosyncratic word usage, illogical reasoning, perceptual confusion, loss of realistic attunement to the task, and loosely related ideas.

The effects of auditory stimulation on the arithmetic performance of children with ADHD and nondisabled children.

This study evaluated the impact of extra-task stimulation on the academic task performance of children with attention-deficit/hyperactivity disorder (ADHD). Twenty boys with ADHD and 20 nondisabled boys worked on an arithmetic task during high stimulation (music), low stimulation (speech), and no stimulation (silence). The music "distractors" were individualized for each child, and the arithmetic problems were at each child's ability level. A significant Group x Condition interaction was found for number of correct answers. Specifically, the nondisabled youngsters performed similarly under all three auditory conditions. In contrast, the children with ADHD did significantly better under the music condition than speech or silence conditions. However, a significant Group x Order interaction indicated that arithmetic performance was enhanced only for those children with ADHD who received music as the first condition. The facilitative effects of salient auditory stimulation on the arithmetic performance of the children with ADHD provide some support for the underarousal/optimal stimulation theory of ADHD.

Effects of late-afternoon methylphenidate administration on behavior and sleep in attention-deficit hyperactivity disorder.

OBJECTIVE: This study evaluated the effects on behavior and sleep of methylphenidate (MPH) administered at 4 PM to children with attention-deficit hyperactivity disorder (ADHD). METHODOLOGY: Twelve children admitted to a child psychiatric inpatient service with ADHD participated in a double-blind, crossover study in which they received a 4 PM dose of either 15 mg of MPH, 10 mg of MPH, or a placebo in random order for 12 consecutive days. Ratings of behavior, including ADHD symptoms, pertaining to the period from dose administration until sleep onset, were supplied nightly by hospital staff. Sleep latency and sleep adequacy were also assessed for each night. RESULTS: MPH resulted in markedly improved behavioral control compared with placebo; there was no difference between 15-mg and 10-mg MPH doses. MPH did not alter sleep latencies observed with the placebo. Children were more often rated as less tired on awakening after nights that they received 10 mg of MPH compared with 15 mg of MPH and the placebo. Weight loss was apparent among 83% of the patients, but dinner intake did not vary with third-dose condition. CONCLUSIONS: Morning and noon administration of stimulants to children with ADHD is a near-universal practice, but many clinicians avoid a third, late-afternoon administration for fear of inducing insomnia. This study's findings show that children with ADHD derive substantial symptom reduction from MPH administered in late afternoon, with no untoward effects on sleep. Therefore, three-times-a-day dosing should be considered for those children exhibiting ADHD symptoms in the evening. Adverse effects on sleep latency were not apparent in the sample overall. Nonetheless, monitoring for possible aggravation of sleep problems and weight loss remains sound treatment practice.

Hospitalizing the suicidal adolescent: an empirical investigation of decision-making criteria.

OBJECTIVE: The primary purpose of this research is to investigate the criteria used by child and adolescent clinicians in determining the appropriateness of hospitalization for suicidal adolescents. METHOD: A questionnaire containing 64 vignettes describing adolescent suicide attempters was completed by a sample of 36 child and adolescent clinicians. Six variables known to relate to lethality of attempt were systematically varied within the vignettes: gender, depression, conduct disorder/substance abuse, previous attempts, suicidal relative, and family supports. Respondents were asked to judge the appropriateness of hospitalization for each vignette. RESULTS: Hospitalization preference was found to be inversely related to professional experience and was significantly predicted by all risk factors except gender. Configural cue utilization added substantially to the efficacy of a linear model in predicting preference to hospitalize. CONCLUSIONS: Experienced clinicians use known risk factors for adolescent suicide in making recommendations to hospitalize, but results also suggest ongoing needs for education and training in adolescent suicidality.

Prevalence of psychiatric symptoms and their relation to adjustment among Chinese-American youth.

OBJECTIVE: The primary purpose of this investigation is to assess psychiatric symptoms of Chinese-American children using Achenbach's Child Behavior Checklist (CBCL) and to determine the impact of acculturation on these symptoms. METHOD: One hundred eighty-one forms of a Chinese CBCL and a 10-item questionnaire on adjustment and ethnic patterns of socialization were completed by a parent or guardian of Chinese-American children attending a Chinese school in New York City. RESULTS: The sample's total problem, internalizing, externalizing, total competence, activities, and social scores were significantly lower than Achenbach's American norms by age and sex. Favorable adjustment was correlated significantly with lower total problem and internalizing scores. Recent immigrants did not have higher symptom scores. CONCLUSION: Lower scores of the Chinese-American children may be due to temperamental differences, underreporting by the respondent, or cultural intolerance of misbehavior.

Children's behavioral adaptation early in psychiatric hospitalization.

Behavioral patterns over time were assessed during the first 24 days of hospitalization for 98 child psychiatric inpatients. Staff completed daily behavioral monitoring and ratings. Patients were categorized as improved, unchanged or deteriorated during this time. Thirty-four percent of patients initially exhibited well-controlled behavior, but then significantly worsened after a period averaging 6.8 days. This result empirically supports the "honeymoon" phenomenon. Other patients showed either improvement during the initial period (15%), no change (30%), or could not be reliably classified (21%). Therefore, many child inpatients show rapid symptom stabilization after admission, but a large number then worsen. Clinical, scientific and administrative implications of these results are discussed.

Teachers' ratings of disruptive behaviors: the influence of halo effects.

This study evaluated the accuracy of teachers' ratings and examined whether these ratings are influenced by halo effects. One hundred thirty-nine elementary school teachers viewed videotapes of what they believed were children in regular fourth-grade classrooms. In fact, the children were actors who followed prepared scripts that depicted a child engaging in behaviors characteristic of an attention-deficit hyperactivity disorder (ADHD), an oppositional defiant disorder or a normal youngster. The findings provide support for a bias that was unidirectional in nature. Specifically, teachers rated hyperactive behaviors accurately when the child behaved like an ADHD youngster. However, ratings of hyperactivity and of ADHD symptomatic behaviors were spuriously inflated when behaviors associated with oppositional defiant disorder occurred. In contrast, teachers rated oppositional and conduct problem behaviors accurately, regardless of the presence of hyperactive behaviors. The implications of these findings regarding diagnostic practices and rating scale formats are discussed.

Imipramine treatment of children with separation anxiety disorder.

The efficacy of imipramine was investigated in 20 children (ages 6 to 15) with separation anxiety disorder. Children were treated for a month with vigorous behavioral treatment. If they did not respond, they entered a double-blind, randomized, 6-week trial of imipramine or placebo. Of 45 children accepted, 21 (47%) entered the trial. About half the children improved with either treatment, and no superiority for imipramine was obtained. There was no instance of clinically significant EKG changes. This small study failed to replicate previous findings of imipramine efficacy in a similar, but larger, clinical population.

Short-term treatment of children with encopresis.

To examine the effectiveness of a short-term behavioral treatment of encopresis, 52 encopretic children were evaluated and treated according to a standardized protocol. The treatment was highly effective, with a significant decrease in soiling during the first month (P < 0.01). Of the children who began treatment, 84.6% successfully reached the criterion of 2 consecutive weeks with no soiling accidents in a mean time of 28 days, and 78.8% successfully completed an additional 7-week phaseout period. The evaluations provided rich descriptive information regarding the characteristics of encopretic children. In agreement with the literature, no specific pattern of behavioral pathology was apparent.

A survey of child and adolescent psychiatry residents: perceptions of the ideal training program.

A survey instrument was developed to examine several issues relevant to training in child and adolescent psychiatry. Forty percent of the residents representing 56% of the training programs in the United States completed the questionnaires. A descriptive profile of the typical training experiences of child and adolescent psychiatry residents is presented, as is a report of their satisfaction with each component of their program and their expectations of an ideal training program. In general, satisfaction with residency training experiences was found to be highly related to the amount of emphasis reportedly placed on the various training experiences. The implications of the findings for training directors are discussed.

Piracetam and dyslexia: effects on reading tests.

Previous research has suggested that dyslexics treated with piracetam have shown improvements in reading skills, verbal memory and verbal conceptualizing ability, feature analysis, and processing of letter-like stimuli. Two hundred twenty-five dyslexic children between the ages of 7 years 6 months and 12 years 11 months whose reading skills were significantly below their intellectual capacity were enrolled in a multicenter, 36-week, double-blind, placebo-controlled study. Children of below average intelligence, with abnormal findings on audiologic, ophthalmologic, neurologic, psychiatric, and physical examinations, who were emotionally disturbed or educationally deprived and who had recently been treated with psychoactive medication were excluded from the trial. Piracetam was well tolerated, with no serious adverse clinical or laboratory effects reported. Piracetam-treated children showed significant improvements in reading ability (Gray Oral Reading Test) and reading comprehension (Gilmore Oral Reading Test). Treatment effects were evident after 12 weeks and were sustained for the total period (36 weeks).