Tolerability of selective serotonin reuptake inhibitors in thirty-nine children under age seven: a retrospective chart review.

OBJECTIVE: To characterize the adverse effects of treatment with selective serotonin reuptake inhibitors (SSRIs) started in children under age 7 yr. METHODS: We conducted a retrospective review of medical records for all children who had begun treatment with an SSRI under age 7 at an academic psychiatry department in Boston. RESULTS: Thirty-nine children (26 males, 13 females) met the inclusion criteria. Mean age at start of treatment was 5.9 +/- 0.8 yr, and median treatment duration was 5.0 months. The target diagnoses for SSRI treatment were anxiety disorders in 54%, depressive disorders in 23%, and both anxiety and depressive disorders in 20% of patients. There were no reports of suicidal ideation or attempt. No children were medically or psychiatrically hospitalized for adverse effects (AEs). Eleven patients (28%) reported an AE of at least moderate severity; 7 (18%) discontinued the SSRI due to the AE. Six patients discontinued due to behavioral activation and 1 due to gastrointestinal upset. The median time to onset of an AE was 23 days, and median resolution was 19 days from onset. CONCLUSIONS: The high rate of adverse effects, especially activation, in this sample argues for continued caution in using SSRIs in young children. Controlled trials are warranted.

Results of random drug testing in an adolescent substance abuse program.

OBJECTIVE: The objective of this study was to estimate from a random urine drug-testing program for adolescents the proportion of drug tests that are susceptible to interpretation errors. METHODS: This was a secondary analysis of a clinical database and chart review from an adolescent outpatient substance abuse program at a large children's hospital. We analyzed from 110 adolescent patients (13-21 years of age) all 710 urine drug test results that were collected between December 2002 and July 2005 and 85 original laboratory reports for tests that were collected between December 2002 and May 2006 and were confirmed positive for opioids. We calculated the percentage of tests that were too dilute to interpret (potential false-negatives) and the percentage of confirmed positive tests for oxycodone that did not result in a positive initial screen (potential false-negatives). We also reviewed clinical information to determine whether confirmed positive tests resulted from legitimate use of prescription or over-the-counter medication (potential false-positives). RESULTS: Of 710 drug tests, 40 negative tests were too dilute to interpret properly, and 45 of 217 positive tests resulted from prescription medication use for a total of 85 tests that were susceptible to error. Of the 85 confirmatory laboratory reports reviewed, 43 were positive for oxycodone, but only 16 of these had produced a positive opiate screen. CONCLUSIONS: Unless proper procedures are used in collecting, analyzing, and interpreting laboratory testing for drugs, there is a substantial risk for error.

Buprenorphine replacement therapy for adolescents with opioid dependence: early experience from a children's hospital-based outpatient treatment program.

Opioid use by adolescents is on the rise and replacement therapy is an effective treatment. Methadone replacement has been used safely and effectively with adults, but methadone programs are often unattractive to teenagers. Buprenorphine is a new replacement therapy that has been shown to be as effective as high dose methadone and may be better suited for the treatment of younger patients. We describe the experiences of several adolescent patients who received treatment from an outpatient adolescent substance abuse program that operates within a children's hospital, with an emphasis on issues of adolescent development.

Adolescent substance use: brief interventions by emergency care providers.

Use of tobacco, alcohol and other drugs plays a major role in adolescent morbidity and mortality. When under the influence of alcohol or other drugs, adolescents are at increased risk for injuries, unprotected sex, or interpersonal violence. Alcohol and other drugs are major factors in adolescent deaths, contributing to motor vehicle crashes, homicides, and suicides. Adolescents tend to have shorter substance use histories therefore they often experience emergency/acute care health treatment resulting from substance use related trauma and/or overdose. Substance use screening of adolescents who present to an Emergency Department (ED) is vitally important. The CRAFFT is a valid and reliable screening tool that was developed for use with adolescents. If an adolescent screens positive, then the next step is to determine their stage of use and readiness for change in preparation for doing a brief intervention. Helping patients to recognize the potential relation between their substance use and health related consequences, may motivate them to decrease their use for harm reduction. Motivational interviewing is an effective, evidence-based approach to helping people change their high risk behavior.

Training high school counselors on the use of motivational interviewing to screen for substance abuse.

Interdisciplinary faculty implemented a project to enhance school personnel's knowledge and skills in screening and motivational interviewing for substance abuse in two Boston high schools.

Implementing a randomized clinical trial on a pediatric psychiatric inpatient unit at a children's hospital: the case of clonidine for post-traumatic stress.

Randomized clinical trials (RCTs) of psychotropic medications are uncommon among child and adolescent populations, and even rarer on pediatric, psychiatric inpatient units. We mention some of these studies, and then discuss the advantages and challenges of conducting a RCT among youngsters on an inpatient psychiatric unit in a pediatric hospital, using as an example our ongoing study of clonidine for intrusive symptoms of post-traumatic stress. Our purpose is to alert potential investigators to the obstacles they may encounter while implementing a RCT, while also pointing the way to potential resources. Advantages of inpatient units for RCTs include easy access to patients, with the potential for careful monitoring of both patients' clinical status and of medication administration. Challenges include the need for the psychiatric researcher to form liaison with other important areas within the hospital, such as the Institutional Review Board, the Pharmacy, and sometimes a General Clinical Research Center and a Clinical Research Program. The functions of these departments are discussed, and additional support for clinicians in hospital settings without these departments is described. Other issues include training clinical nurses to conduct research while making adequate provisions for their time to do so. Attitudes on a clinical psychiatric inpatient unit toward research also merit consideration. Furthermore, as with any study in a hospital setting, recruitment presents its own set of challenges. Finally, one must be cognizant of how clinical information flows between clinicians and researchers.

Office-based intervention for adolescent substance abuse.

Because substance use is highly prevalent among teens, primary care clinicians may not be able to refer all adolescents to drug counselors or mental health care professionals. Pediatricians may therefore find it useful to use the basic principles of office intervention and reserve referral for those patients with the most significant drug and alcohol problems. Brief interventions have proven effective in reducing problematic drinking among adults, and early work among adolescents is promising. Effective interventions include feedback on risks and problems, an emphasis on personal responsibility, a menu of alternatives for change, an empathetic approach, and reinforcement of patient self-efficacy. Motivational interviewing is an effective means of enhancing success in counseling. When a referral is necessary, motivational interviewing can be used to maximize adherence.