Affective Disorders with Psychosis in Youth: An Update.

Mood disorders, including major depression and mania, can present with psychotic features. In youth psychotic-like phenomena such as "seeing faces in the dark" or "hearing noises" are fairly common. Rates of lifetime psychotic symptoms are much higher than rates of psychosis during a "current" episode of mania or depression in youth. Psychotic phenomena can be mood congruent or incongruent. A detailed mental status examination and clinical history include questioning to ensure the informants understand the questions being asked. There are interviews that structure how questions are asked, and rating scales that help anchor severity and quality of the mood episode.

Understanding Early Age of Onset: a Review of the Last 5 Years.

The age at onset of bipolar disorder ranging from childhood to adolescent to adult has significant implications for frequency, severity and duration of mood episodes, comorbid psychopathology, heritability, response to treatment, and opportunity for early intervention. There is increasing evidence that recognition of prodromal symptoms in at-risk populations and mood type at onset are important variables in understanding the course of this illness in youth. Very early childhood onset of symptoms including anxiety/depression, mood lability, and subthreshold manic symptoms, along with family history of a parent with early onset bipolar disorder, appears to predict the highest risk of early onset disorder with the most severe course.

Major Depressive Disorder Among Children and Adolescents.

Depression among youths remains a public health concern, particularly because only a fraction of affected youths receive treatment. To obtain treatment, youths with depression must first be identified so that early intervention can occur. Furthermore, investigation of both more effective pharmacological agents and more widespread accessibility of cognitive-behavioral interventions are necessary. To address unmet needs in the identification and treatment of depression among youths, clinical counseling programs are being developed in primary care clinics and in schools to identify and treat depressive symptoms or milder major depressive disorder and have shown promising outcomes thus far in reducing depression and increasing quality of life.

Bipolar Disorder Among Children and Adolescents.

Although for years it was felt to be almost nonexistent, very-early-onset bipolar disorder (before age 12) has become an important member of the mood disorder spectrum of youths. Whether there is a separate subtype characterized by severe irritability or whether the problem of emotionally explosive children is better explained by other conditions is still being resolved. The diagnosis of bipolar I disorder requires an episode of mania, and understanding those manic symptoms is the source of differences in interpretation.

Disruptive Mood Dysregulation Disorder Among Children and Adolescents.

Disruptive mood dysregulation disorder (DMDD) was introduced in the mood disorders section of DSM-5. Its primary symptoms are "severe, recurrent temper outbursts" (manifested verbally and/or physically) superimposed on and associated with chronic irritability. DMDD is a condition with an early age of onset (i.e., symptoms apparent by age 10, although the diagnosis cannot be made before age 6); however, nothing is known about the condition among adults in part because questions about temper outbursts (versus "often losing temper") are not consistently asked after 6 years of age. Other qualifiers are present so that better-known conditions are not overlooked. For instance, manic symptoms that are present for more than 1 day, symptoms that are not exclusively occurring during major depressive disorder, or symptoms that are better explained by autism, posttraumatic stress disorder, separation anxiety, and dysthymia are exclusionary. Although DMDD can co-occur with attention-deficit hyperactivity disorder (ADHD), conduct disorder, and substance use disorder, it preempts diagnoses of both oppositional defiant disorder and intermittent explosive disorder.

The comorbidity of ADHD and bipolar disorder: any less confusion?

The clinical confusion surrounding childhood ADHD and bipolar disorder centers on overlaps between severe ADHD with mood lability and mania/hypomania. Perplexity has been exacerbated by the removal of mood symptoms from the diagnostic criteria for ADHD and a lack of stringent criteria for a manic/hypomanic episode. This review summarizes current knowledge of the relationship between ADHD and bipolar disorder, the rates with which ADHD and bipolar disorder coexist in youth of differing ages, their presence in community, clinical, and high risk samples, and their longitudinal course. Treatment studies are reviewed, highlighting findings in comorbid cases, which support the efficacy of stimulants and other agents for ADHD without worsening mood symptoms, and efficacy of second generation antipsychotics for bipolar disorder. In conclusion, a lack of clarity regarding the diagnostic boundaries between childhood ADHD and bipolar disorder remains, however, treatments targeting symptoms of each disorder when comorbid, provide some efficacy.

Reflective team supervision after a frightening event on a psychiatric crisis service.

OBJECTIVE: The authors demonstrate the value of reflective team supervision as part of the informal curriculum in an emergency psychiatry setting after a potentially traumatizing adverse event. METHOD: The article gives a case presentation of a violent adolescent who eloped from his hospital Emergency Department and provides a description of team supervision sessions that facilitated informal learning for residents and medical students after this event. RESULTS: Reflective team supervision sessions after this event resulted both in improved resident well-being and learning opportunities, as well as hospital quality improvement designed to prevent future elopements. CONCLUSIONS: Reflective team supervision can be an essential component of trainee education to enhance residents' well-being and to promote both systems-based practice and practice-based learning. This can be an excellent forum to explore themes of humility, self-reflection, and professional growth.

Objective structured clinical interview training using a virtual human patient.

Effective interview skills are a core competency for psychiatry residents and developing psychotherapists. Although schools commonly make use of standardized patients to teach interview skills, the diversity of the scenarios standardized patients can characterize is limited by availability of human actors. Further, there is the economic concern related to the time and money needed to train standardized patients. Perhaps most damaging is the "standardization" of standardized patients -- will they in fact consistently proffer psychometrically reliable and valid interactions with the training clinicians. Virtual Human Agent (VHA) technology has evolved to a point where researchers may begin developing mental health applications that make use of virtual reality patients. The work presented here is a preliminary attempt at what we believe to be a large application area. Herein we describe an ongoing study of our virtual patients (VP). We present an approach that allows novice mental health clinicians to conduct an interview with a virtual character that emulates an adolescent male with conduct disorder. This study illustrates the ways in which a variety of core research components developed at the University of Southern California facilitates the rapid development of mental health applications.

Mindfulness meditation training in adults and adolescents with ADHD: a feasibility study.

OBJECTIVE: ADHD is a childhood-onset psychiatric condition that often continues into adulthood. Stimulant medications are the mainstay of treatment; however, additional approaches are frequently desired. In recent years, mindfulness meditation has been proposed to improve attention, reduce stress, and improve mood. This study tests the feasibility of an 8-week mindfulness training program for adults and adolescents with ADHD. METHOD: Twenty-four adults and eight adolescents with ADHD enrolled in a feasibility study of an 8-week mindfulness training program. RESULTS: The majority of participants completed the training and reported high satisfaction with the training. Pre-post improvements in self-reported ADHD symptoms and test performance on tasks measuring attention and cognitive inhibition were noted. Improvements in anxiety and depressive symptoms were also observed. CONCLUSION: Mindfulness training is a feasible intervention in a subset of ADHD adults and adolescents and may improve behavioral and neurocognitive impairments. A controlled clinical study is warranted.

Dexmethylphenidate extended-release capsules for attention deficit hyperactivity disorder.

Medications for attention deficit hyperactivity disorder (ADHD) currently represent the ninth largest segment of the CNS market by sales, with 2.4 billion USD spent annually on this condition and 40% annual growth. Stimulant medications remain the most effective ADHD therapies and provide robust improvement in ADHD symptoms in both youth and adults. Current prescribing practices favor extended release preparations due to increased convenience, compliance and tolerability with once-daily dosing. Dexmethylphenidate extended release is a long-acting preparation of the ADHD medication Focalin (dexmethylphenidate immediate release) and was approved for marketing by the US Food and Drug administration in June 2005. Dexmethylphenidate consists of the single dextro-isomer form of d,l-methylphenidate commonly marketed as Ritalin. Dexmethylphenidate extended release utilizes spheroidal oral drug absorption system technology to achieve a 50% immediate medication delivery and 50% delayed release of dexmethylphenidate approximately 4 h after ingestion. Placebo-controlled, clinical trials in children and adults with ADHD have demonstrated efficacy for behavioral and academic ratings, with an analog classroom study showing medication effects up to 12 h after dosing. Dexmethylphenidate extended release was generally well tolerated with a side-effect profile similar to other stimulants. The most common reported side effects include diminished appetite and insomnia. Given its duration of effect, favorable tolerability and flexibility in dosing, dexmethylphenidate extended release is likely to gain considerable use as an ADHD treatment.

The impact of terrorism on children and adolescents: terror in the skies, terror on television.

Terrorist attacks and their aftermath have had a powerful impact on children and their families. Media and television exposure of terrorist events throughout the world has increased during the past few years. There is increasing concern about the effects of this exposure on children who witness these violent images. To develop a proactive and strategic response to reactions of fear, clinicians, educators, and policy makers must understand the psychologic effects of media coverage of terrorism on children. Previous research has focused on media coverage of criminal violence and war. Recent studies have examined the effect of remote exposure of terrorist attacks and have shown a significant clinical impact on children and families.

The functional assessment of media in child and adolescent psychiatric treatment.

Clinicians and parents share a responsibility to educate themselves in how young people communicate with each other and how it impacts on communication with the adults in their lives. The greater fluency that clinicians have with the world of youth, the easier it is to begin a meaningful dialogue with young people. Such a dialogue always has been the purview of clinicians interested in the developmental trajectory of their young patients. The enormity of media exposure and the changes that characterize current media formats make such a dialogue important and challenging. From watching video clips to listening to music, this assessment affords clinicians a snapshot into the milieu of the modern young world. The dialogue is "virtually" always well worth the effort.

New drugs for the treatment of attention-deficit/hyperactivity disorder.

Attention-deficit/hyperactivity disorder (ADHD) is the most common neuropsychiatric disorder of childhood. Recent research indicates that ADHD most often persists into adolescence and adulthood, and is associated with impairments in academic, social and occupational functioning. The ADHD diagnosis is based on history and clinical examination. There are no objective laboratory measures for diagnosis. ADHD is largely heritable. Its underlying pathophysiology has been theorised to include dysregulation of inhibitory noradrenergic frontocortical activity on dopaminergic striatal structures. Evidence shows that ADHD is highly responsive to pharmacological treatments resulting in global functional improvements. Although pharmacotherapy is recognised as the most effective treatment, additional components to optimise ADHD management include proper educational placement, parent management training and social skills development. Central nervous system stimulants, specifically methylphenidate and amphetamine, remain first-line pharmacological treatments. Atomoxetine, a selective noradrenergic re-uptake inhibitor, is the first non-stimulant compound to receive FDA approval for paediatric and adult ADHD. Other medication classes, including alpha-agonist antihypertensives, tricyclic antidepressants, other antidepressants such as buproprion, and the wake-promoting agent modafinil, are prescribed in off-label therapy. Ongoing development of new ADHD medications is expected to emphasise alternative and extended-release delivery systems and non-stimulant compounds.

Second-generation antipsychotic medications in children and adolescents.

OBJECTIVE: We reviewed available pediatric literature on second-generation antipsychotic medications to assess current evidence of efficacy and safety. METHOD: An English language MEDLINE search (1974-2003) was conducted using key words-atypical antipsychotics, children and adolescents, toxicity, clozapine, risperidone, olanzapine, quetiapine, ziprasidone, and aripiprazole. Additional efficacy and safety data were obtained from drug manufacturers. RESULTS: We identified 176 reports, including 15 double-blind, controlled trials, 58 openlabel studies, 18 retrospective chart reviews, and 85 case series/reports. The majority of these studies (43%) were of risperidone. Evidence suggests that second-generation antipsychotics are efficacious in the treatment of psychosis, bipolar disorders, pervasive developmental disorders, and Tourette's Disorder, and are potentially useful in mental retardation, conduct disorder, and severe attention deficit hyperactivity disorder (ADHD). The most frequently reported side effects included cardiovascular effects, weight gain, sedation, sialorrhea, extrapyramidal signs, and hyperprolactinemia, although the relative frequencies of these untoward effects vary among medications. CONCLUSION: Although the evidence base for pediatric use of second-generation antipsychotics is expanding, the majority of available studies are anecdotal, or short-term, openlabel trials. Reports suggest that these compounds are effective for a variety of psychiatric disorders in children and adolescents, but additional double-blind, controlled studies are required to establish definitive efficacy. Although these medications appear to be well tolerated in short-term studies, long-term follow-up investigations and ongoing clinical monitoring are necessary to confirm their safety in this age group.

Mood stabilizers in hospitalized children with bipolar disorder: a retrospective review.

A paucity of naturalistic data supported a rationale for the present retrospective review of clinical changes during hospitalization in 44 bipolar pre-adolescents, treated with monotherapy lithium, carbamazepine (CBZ) or divalproex sodium (DVP). Daily staff progress notes and discharge summaries on each patient were read by four trained clinicians blind to treatment group, and rated according to the Clinical Global Impression Improvement (CGI-I) scale. Consensus rating was measured by kappa reliability. Data were analyzed using a general linear model (sas mixed) analysis of variance (anova) with repeated measures. The medication groups did not differ in length of hospitalization, overall severity of illness at the time of admission, or comorbidity. Prior treatment was considered as a covariate. Each group approached serum therapeutic levels at day 7 of the medication period. The estimated mean CGI-I scores for CBZ were systematically higher (i.e. worse) than those for lithium and DVP, which overlapped and crossed over time. The difference became increasingly apparent and was statistically significant by week 2 (P = 0.036). The present study was limited in that the sample sizes, particularly in the case of CBZ, were small, commensurate with the low prevalence of the disorder. Lack of structured interviews, as an independent assessment of diagnoses was an intrinsic limitation of the study. Although constrained by its retrospective nature, our findings suggest that by week 2 of hospitalization both lithium and DVP may be more efficacious than CBZ in bipolar pre-adolescents. Any significant finding must be viewed as tentative and subject to confirmation in other studies.

Analog classroom assessment of a once-daily mixed amphetamine formulation, SLI381 (Adderall XR), in children with ADHD.

OBJECTIVES: This investigation was conducted primarily to assess the safety and efficacy of SLI381 (Adderall XR), developed as a once-daily treatment for children with attention-deficit/hyperactivity disorder (ADHD). Secondary objectives included examination of the time course, pharmacokinetic, and pharmacodynamic properties of SLI381. METHOD: This was a randomized, double-blind, crossover study of three doses of SLI381 (10, 20, and 30 mg), placebo, and an active control (Adderall 10 mg) given once daily to 51 children with ADHD. Weekly assessments in an analog classroom setting included blind ratings of attention and deportment and a performance measure (math test) obtained every 1.5 hours over a 12-hour period. RESULTS: SLI381 was well tolerated. All active treatment conditions displayed significant time course effects and were superior to placebo in improving efficacy measures. Dose-dependent improvements were evident for SLI381. SLI381 20 and 30 mg and Adderall all showed rapid improvements by 1.5 hours, but only the SLI381 20- and 30-mg doses showed continued activity at 10.5 and 12 hours for classroom behavior and math test performance versus placebo. CONCLUSIONS: These data provide support for the benefit of this novel, once-daily amphetamine preparation in the treatment of ADHD. The longer duration of action of SLI381 has the potential to simplify psychostimulant dosing, thus reducing dose diversion and eliminating the need for in-school administration. SLI381 appears to be a useful treatment option for many children with ADHD.

From Alice Cooper to Marilyn Manson: the significance of adolescent antiheroes.

Every generation has icons attractive to adolescents and equally repugnant to adults. This article examines antihero characteristics, their appeal to adolescents, and how adults can respond to adolescents enamored of antiheroes. The stage personas of antiheroes champion rejection of the mainstream, assail adult constraints and expectations, explore frightening topics, and ultimately fulfill the adolescent fantasy of surviving alienation and emerging victorious over parents and peers. But antihero idolization also tests the adult's defenses. Adults, fearing loss of control and rejection by the adolescent, sometimes resort to primitive defenses mismatched to the developmental needs of the adolescent. Adults, as much as the adolescents, benefit from examining their individual reactions to the antihero and how their current relationship can accommodate this intrusion. The antihero phenomenon presents adults with an opportunity to model ways to think through that which is uncomfortable and to navigate together the adolescent's developmentally normative separation efforts.