Substance Use Disorders and Psychiatric Illness Among Transitional Age Youth Experiencing Homelessness.

Objective: Transitional age youth experiencing homelessness (TAY-EH) bear a high burden of substance use disorders (SUDs) and psychopathology. However, limited data exist on the co-occurrence and interactions between these diagnoses in this marginalized group. This study sought to identify rates of single and co-occurring SUDs and psychiatric diagnoses among a sample of TAY-EH and to investigate associations between psychopathology and prevalence and severity of SUDs in this group. Method: TAY-EH accessing a low-threshold social service agency in a large metropolitan area completed psychosocial and diagnostic interviews to assess for SUDs and psychopathology. Analyses examined rates of single and co-occurring disorders and associations between burden of psychopathology and presence and severity of SUDs. Results: The assessment was completed by 140 TAY-EH; the majority were youth of color (54% Black/African American, 16% Latinx), and 57% identified as male. Rates of single and co-occurring psychiatric disorders and specific SUDs (cannabis use disorder [CUD] and alcohol use disorder [AUD]) were notably high. An increasing number of psychiatric diagnoses was significantly associated with elevated CUD/AUD prevalence and severity. Mood, anxiety, attention-deficit/hyperactivity, and antisocial personality disorders were significantly associated with elevated CUD/AUD prevalence and severity, as was suicidality (all p < .05). Conclusion: This study reveals a complex overlay of SUDs and psychopathology facing TAY-EH, with a significant association between co-occurring psychopathology and severity of CUD/AUD. To the authors' knowledge, this is the first study to examine associations between specific psychopathology and severity of SUDs among TAY-EH. Further research into the mechanistic and temporal links between these conditions is needed to inform tailored treatment interventions.

A "Proof of Concept" Randomized Controlled Trial of a Video Game Requiring Emotional Regulation to Augment Anger Control Training.

Emotional dysregulation leading to clinically significant anger and aggression is a common and substantial concern for youth and their families. While psychotropic medications and cognitive behavioral therapies can be effective, these modalities suffer from drawbacks such as significant side effects, high rates of attrition, and lack of real-world skill translation. Regulate and Gain Emotional Control (RAGE-Control) is a video game designed as an engaging augment to existing treatments. The game facilitates emotional regulation skill building through practice modulating physiological arousal while completing a challenging inhibitory task. We compared reduction in anger, aggression, oppositionality, and global severity between two treatment conditions: Anger Control Training (ACT) augmented with RAGE-Control and ACT with a sham version of the game, in a pilot double-blind randomized controlled trial. To begin to understand mechanisms of change, we examined heart rate during game play over the course of the study and explored associations between symptom changes and heart rate changes. Materials and Methods: Forty youth with clinically significant anger dyscontrol (age 10-17) were randomly assigned to 10 sessions of ACT with RAGE-Control or ACT with sham video game. Results: Both treatments similarly reduced self-reported anger. However, ACT with RAGE-Control led to larger improvements in aggression (CI: -17 to -1.0, ES: 0.55, p = 0.015); oppositionality (CI: -9.0 to -7e-6, ES: 0.48, p = 0.032); and global severity (CI: -1.0 to -5e-6, ES: 0.51, p = 0.023) relative to sham. Participants in the RAGE-Control group saw a decrease in median heart rate during game play (ß = 1.2, p < 0.001). Larger pre to post decreases in heart rate were significantly associated with larger pre to post decreases in aggression and oppositional behaviors. Discussion: Augmenting ACT with RAGE-Control reduced behavioral expression of anger, but not the experience of angry feelings, as compared to ACT with a sham version of the game. Increased heart rate control, demonstrated by reduction in median heart rate during gameplay, was associated with decreased aggression and oppositional behavior. Together these findings support that augmenting traditional treatment with technology facilitating heart rate control through skill practice translates to enhancements in real-life behavioral change. Therefore, further exploration into engaging skill-focused games such as RAGE-Control is warranted. Clinical Trial Registration:ClinicalTrials.gov, identifier: NCT01551732.

RAGE Control: Regulate and Gain Emotional Control.

Advances in neurobiology and computer science make possible interventions designed to strengthen basic processes behind emotional control. We present one such computer-based intervention, RAGE Control (Regulate And Gain Emotional Control). This extends the usual paradigm of biofeedback by requiring relaxation in the midst of engaging executive processes in a quick reaction task. RAGE Control teaches children to simultaneously focus, react, inhibit impulses, and keep their heart rate down in the context of a traditional space battle game. The program is grounded in the theory of Cognitive Behavioral Therapy and is currently in clinical use by psychotherapists at Children's Hospital in Boston. It aims to reduce the need for psychotropic medication to help children gain emotional control. Clinical trials to test the promise of this technology are warranted.

Effect of 2 psychotherapies on depression and disease activity in pediatric Crohn's disease.

BACKGROUND: Crohn's disease (CD) is associated with depression. It is unclear if psychosocial interventions offer benefit for depressive symptoms during active CD. In this secondary analysis of a larger study of treating depression in pediatric inflammatory bowel disease, we assessed whether cognitive behavioral therapy (CBT) would differentiate from supportive nondirective therapy in treating depression and disease activity in youth with CD. We also explored whether somatic depressive symptoms showed a different pattern of response in the overall sample and the subset with active inflammatory bowel disease. METHODS: Youth with depression and CD (n = 161) were randomized to 3 months of CBT (teaching coping skills) or supportive nondirective therapy (supportive listening). Depressive severity was measured using the Children's Depression Rating Scale-Revised (CDRS-R) with the somatic depressive subtype consisting of those CDRS-R items, which significantly correlated with CD activity. Disease activity was measured by the Pediatric Crohn's disease Activity Index. Given the potential confound of higher dose steroids, subanalyses excluded subjects on >20 mg/d prednisone equivalent (n = 34). RESULTS: Total CDRS-R scores in the overall sample significantly decreased over time after both treatments (P < 0.0001). Treatment with CBT was associated with a significantly greater improvement in the Pediatric Crohn's disease Activity Index (P = 0.05) and somatic depressive subtype (P = 0.03) in those with active inflammatory bowel disease (n = 95) compared with supportive nondirective therapy. After excluding those on steroids (n = 34), there was a significant improvement in total CDRS-R (P = 0.03) and in Pediatric Crohn's disease Activity Index (P = 0.03) after CBT. CONCLUSIONS: Psychotherapy may be a useful adjunct to treat depression in the context of CD-related inflammation in youth who are not concurrently on higher dose steroids.

Randomized efficacy trial of two psychotherapies for depression in youth with inflammatory bowel disease.

OBJECTIVE: Pediatric inflammatory bowel disease (IBD) is associated with high rates of depression. This study compared the efficacy of cognitive behavioral therapy (CBT) to supportive nondirective therapy (SNDT) in treating youth with comorbid IBD and depression. METHOD: Youth (51% female and 49% male; age 9-17 years, mean age 14.3 years) with depression and Crohn's disease (n = 161) or ulcerative colitis (n = 56) were randomly assigned to a 3-month course of CBT or SNDT. The primary outcome was comparative reduction in depressive symptom severity; secondary outcomes were depression remission, increase in depression response, and improved health-related adjustment and IBD activity. RESULTS: A total of 178 participants (82%) completed the 3-month intervention. Both psychotherapies resulted in significant reductions in total Children's Depression Rating Scale Revised score (37.3% for CBT and 31.9% for SNDT), but the difference between the 2 treatments was not significant (p = .16). There were large pre-post effect sizes for each treatment (d = 1.31 for CBT and d = 1.30 for SNDT). More than 65% of youth had a complete remission of depression at 3 months, with no difference between CBT and SNDT (67.8% and 63.2%, respectively). Compared to SNDT, CBT was associated with a greater reduction in IBD activity (p = .04) but no greater improvement on the Clinical Global Assessment Scale (p = .06) and health-related quality of life (IMPACT-III scale) (p = .07). CONCLUSION: This is the first randomized controlled study to suggest improvements in depression severity, global functioning, quality of life, and disease activity in a physically ill pediatric cohort treated with psychotherapy. Clinical trial registration information-Reducing Depressive Symptoms in Physically Ill Youth; http://clinical trials.gov; NCT00534911.

"RAGE-Control": A Game to Build Emotional Strength.

Emotional regulation is an important skill, and some children require extra support to develop that skill. To address this need, we have built an active biofeedback videogame and incorporated the game into a cognitive behavioral therapy. Our approach requires that players simultaneously attend to a demanding task and still maintain emotional control, forcing practice and skill building in both domains concurrently. Early studies have shown that our approach improves emotional control compared with treatment as usual and has led to promising new developments of emotionally aware toys that can reach younger children.

The overlap of functional abdominal pain in pediatric Crohn's disease.

BACKGROUND: Children with Crohn's disease (CD) may report abdominal pain despite clinical remission, suggesting that functional abdominal pain (FAP) may be playing a role. The aim of this study was to explore the presence and impact of FAP in children with CD in remission. METHODS: Children, aged 9 to 17 years, with CD were enrolled. Demographic information, the Pediatric Crohn's Disease Activity Index, and the Children's Depression Inventory were obtained. Disease remission was defined by physician global assessment, normal laboratories findings, absence of 3 or more stools a day, nocturnal stooling, bloody diarrhea, concurrent steroid therapy, strictures, or disease flare within 6 months. FAP was defined as patients with abdominal pain and CD remission. Rates of depression (Children's Depression Inventory >9) were compared. RESULTS: Of 307 children, 139 reported abdominal pain. Of this group, 18 of 139 (13%) children met the criteria for FAP. Despite clinical remission, 8 of 18 patients with CD having FAP were classified with active disease by Pediatric Crohn's Disease Activity Index. These patients had a higher rate of depression than patients with CD in remission with no abdominal pain (55.6% versus 29.9%; P = 0.03), similar to patients with abdominal pain from active CD (55.6% versus 44.8%; P = 0.62). CONCLUSIONS: A proportion of children with CD in remission have FAP. These children are at significant risk of depression. Future studies are needed to determine whether depression contributes to functional pain development or if pain itself leads to depression. Especially given that functional pain may exaggerate disease activity, clinicians caring for children with CD and FAP should consider evaluating for depressive disorders before escalating therapy.

The Use of Antiepileptic Drugs (AEDs) for the Treatment of Pediatric Aggression and Mood Disorders.

Aggressive symptomatology presents across multiple psychiatric, developmental, neurological and behavioral disorders, complicating the diagnosis and treatment of the underlying pathology. Anti-Epileptic Drugs (AEDs) have become an appealing alternative in the treatment of aggression, mood lability and impulsivity in adult and pediatric populations, although few controlled trials have explored their efficacy in treating pediatric populations. This review of the literature synthesizes the available data on ten AEDs - valproate, carbamazepine, oxcarbazepine, phenytoin, lamotrigine, topiramate, levetiracetam, zonisamide, gabapentin and tiagabine - in an attempt to assess evidence for the efficacy of AEDs in the treatment of aggression in pediatric populations. Our review revealed modest evidence that some of the AEDs produced improvement in pediatric aggression, but controlled trials in pediatric bipolar disorder have not been promising. Valproate is the best supported AED for aggression and should be considered as a first line of treatment. When monotherapy is insufficient, combining an AED with either lithium or an atypical anti-psychotic can result in better efficacy. Additionally, our review indicates that medications with predominately GABA-ergic mechanisms of action are not effective in treating aggression, and medications which decrease glutaminergic transmission tended to have more cognitive adverse effects. Agents with multiple mechanisms of action may be more effective.