Adults with autism spectrum disorder: Updated considerations for healthcare providers.

Children with autism spectrum disorder (ASD) eventually grow up and need to make the transition from pediatric services to adult. This is a diverse patient population.

Identifying, evaluating, diagnosing, and treating ADHD in minority youth.

OBJECTIVE: This literature review describes evaluation and treatment of minority youth with ADHD. METHOD: A search of databases for reports of ADHD in minority children was conducted. RESULTS: Interpretation of behavior varies among parents, as does their trust in health care providers and school personnel. Parents desire to avoid stigmatization of their children from diagnostic labels and medications. They may not understand the sequelae of inadequate treatment or fear side effects of treatment. Children respond to stimulant medication but fare better when it is combined with regularly scheduled psychosocial treatment, including education and support for parents. Financial struggles affect access, evaluation, and treatment. Community support is desperately needed to gain parental trust. Creative planning allows health care providers and neighborhood leaders to join in, benefiting the children. CONCLUSION: Quality evaluation by a competent provider, careful choice of assessment tools, clear communication with parents, and close follow-up of progress are all needed.

Psychiatric comorbidity in 36 adults with mitochondrial cytopathies.

INTRODUCTION: Mitochondria are intracellular organelles involved in adenosine triphosphate production. The literature has established the presence of mitochondrial dysfunction in some subjects with psychiatric disorders. Also, there are multiple reports of patients with mitochondrial dysfunction who have various psychiatric disorders. Although the literature on mitochondrial dysfunction and its relation to psychiatric disorders is growing, there remain many unanswered questions. OBJECTIVE: To review subjects with mitochondrial cytopathies for prevalence of psychiatric comorbidity. METHODS: For this study, 36 adults were interviewed. The Mini International Neuropsychiatric Interview and the Short-Form 36 Health Survey, version 1 were used. RESULTS: Lifetime diagnoses included 54% major depressive disorder, 17% bipolar disorder, and 11% panic disorder. These prevalence rates are compared with the general population and subjects with cancer and epilepsy. Subjects with a comorbid psychiatric diagnosis were older (P=.05), had more hospital admissions (P=.02), more medical conditions (P=.01), and lower quality of life (P=.01) than subjects with mitochondrial disease alone. CONCLUSION: Clinicians caring for persons with mitochondrial cytopathies should note the high prevalence of psychiatric problems. Also, this comorbidity might have etiological and therapeutic implications.

Posttraumatic stress disorder in primary care patients.

Posttraumatic stress disorder (PTSD) is a common psychiatric condition. PTSD patients can present with a wide variety of symptoms, and these patients are also at a higher risk of other physical, psychiatric, and substance abuse problems. Recent advances in the treatment of this condition can help the majority of patients with PTSD. Early detection, initiation of appropriate treatment, and timely referral are crucial in the proper management of PTSD.

Patients with challenging behaviors: Communication strategies.

Some patients have behaviors that make interactions unpleasant, sometimes contributing to suboptimal outcomes and physician burnout. Understanding common difficult personality types can help doctors plan effective strategies for dealing with each, resulting in more effective communication, less stress, and better health outcomes.

Major depression with psychosis after resection of a giant middle fossa hemangiopericytoma.

BACKGROUND: Postoperative onset of acute major depression in a patient with no previous history of psychiatric disorder is highly unexpected after skull base surgery. CASE DESCRIPTION: A 38-year-old woman with no previous physical or mental illness presented with a 3-month history of left ear pain, short-term memory disturbance, and motor dysphasia. Magnetic resonance imaging revealed a large extraaxial tumor in the left middle fossa. Left temporal craniotomy was performed, achieving complete tumor resection. The patient showed signs of confusion, disorientation, and severe depression 3 days after the surgery. She developed insomnia and auditory hallucinations along with expressed suicidal ideation, then deteriorated rapidly, necessitating a transfer to a psychiatric unit. In spite of the intensive treatment with antidepressive and antipsychotic medications, she continued to have prolonged psychotic symptoms and depression for several months after surgery. CONCLUSION: Although the incidence is rare, psychiatric complications should be anticipated in patients undergoing resection of a large skull base tumor affecting the temporal lobe. The exact mechanism in this process is not clear; however, it is important to clinically differentiate treatable etiologies such as steroid-induced psychosis and postoperative delirium.

Deficits in diagnosis, treatment and continuity of care in African-American children and adolescents with ADHD.

Despite the evidence that attention-deficit/hyperactivity disorder (ADHD) is not just a diagnosis of whites, it often goes undiagnosed and is underresearched in the African-American population. There are higher rates of delinquency, incarceration, teen pregnancy and sexually transmitted diseases associated with inadequate or delayed treatment of ADHD. Afrcan Americans generally respond well to treatments, but access to evaluation, medication and psychotherapy is limited or absent for many, The purpose of this research is to compare descriptive characteristics of African-American children with ADHD to age-matched Caucasian children with the same diagnosis. Age at diagnosis, treatment offered, perception of outcome, adherence, comorbid symptoms and frequency of follow-up were collected retrospectively from charts of children treated in the sections of child and adolescent psychiatry and pediatric neurology.

Diagnosing and managing posttraumatic stress disorder.

In addition to being associated with combat, posttraumatic stress disorder (PTSD) also occurs in civilians exposed to severe trauma or serious illness. Manifestations of PTSD are varied and commonly include nonspecific physical symptoms, sleep disturbances, and psychological problems. Treatment with selective serotonin reuptake inhibitors (SSRIs) is usually effective.

Pharmacological treatment of neuropsychiatric symptoms of dementia: a review of the evidence.

STUDY DESIGN AND OBJECTIVE: Systemic review of double-blind, placebo-controlled, randomized controlled trials (RCTs) and meta-analyses of medication efficacy in the treatment of patients diagnosed with dementia and experiencing neuropsychiatric symptoms(hallucinations, delusions, agitation, aggression, combativeness, wandering). EXCLUSION CRITERIA: Studies were excluded if they reported only depression, if the medication was not available no longer used in the United States, or duplicated another study already included. DATA SOURCES: Medline of English articles between 1966 and June 2004, Cochrane Database of Systematic Reviews, and a manual search by the authors for other relevant articles. OUTCOMES: Diverse outcome measures ranging from global benefit to behavioral rating scales. Some of the 29 reports listed several instruments; in total, 24 rating scales were used. Statistical outcome was described and some, but not all, noted clinical impression. Adverse outcomes were listed. RESULTS: The results were clustered in groups: conventional antipsychotics, atypicals, antidepressants, cholinesterase inhibitors, mood stabilizers, and others. Treatment duration ranged from 17 days to 16 weeks. Types of dementia and levels of severity varied. The authors reported little benefit and some evidence for harm for typical (or conventional) agents. In contrast, some RCTs of atypical antipsychotics reported "modest" benefit, with olanzapine and risperidone leading others. Although trials reported minimal side effects at low doses, authors acknowledged an increased risk for stroke. No studies adequately compared benefit of typical with atypical agents. With the possible exception of citalopram, antidepressant agents did not reduce agitation, but did improve depression. Cholinesterase inhibiting agents demonstrated significant efficacy toward behavior, while memantine had mixed results. Valproate did not prove to be efficacious, and results for carbamazepine were conflicting.

Munchausen by proxy: a case, chart series, and literature review of older victims.

UNLABELLED: The history of an older child victim of Munchausen by proxy (MBP) is described. He was referred for evaluation after repeated sinus surgeries for recurrent sinus infections believed to be related to a falsified history of an immunodeficiency. The perpetrator was the mother of this 14-year-old victim, consistent with the majority of such cases. This case prompted a review of cases of MBP in older children reported in our hospital as well as a literature search for other cases in older children. METHODS: This study was a chart review of children over 6 years of age who had been evaluated by social services at the Children's Hospital at the Cleveland Clinic and reported as cases of Munchausen by proxy to Child Protective Services between January 2001 and June 2003. Also, an OVID, Psychline, and Pubmed literature review of published cases of Munchausen by proxy were identified, and cases occurring in the older child were selected for review. RESULTS: Older children who are the victims of Munchausen by proxy may have an induced illness, but falsified reports of symptoms and medical history to coerce the child to undergo medical procedures may be more common. Collusion of the victim with the perpetrator may also become a factor as the child ages and adopts the deception. Given the complex relationship that exists between the parent and child, it is difficult to predict whether the victim either will assist the caregiver in maintaining the factitious illness or be able to recognize the falsification. CONCLUSIONS: Older children who are the victims of Munchausen by proxy may fear consequences of revealing the factitious illness. Physicians must consider the possibility of this diagnosis whenever there are discrepancies in a child's illness that makes a factitious illness a consideration.

Factitious disorder and malingering in adolescent girls: case series and literature review.

Six cases of factitious disease and malingering in pediatric patients referred to an infectious diseases practice in a tertiary care children's hospital are described, and implications for general clinical practice are reviewed. All patients were girls aged 9-15 years. Two patients were malingering with the secondary gain of avoiding attendance at school. The other 4 patients presented with factitious illness without clear link to secondary gain, but rather for a psychological purpose. Three of the subjects admitted to self-induced or feigned illness. The 2 patients diagnosed with malingering did very well with early parental support, psychotherapy, and attention paid to school difficulties. The outcomes of the others with underlying psychological conflicts were less resolved. Factitious disorders and malingering occur in the pediatric population. A high index of suspicion is needed for prompt diagnosis and care.

Does Systemic Inflammation Play a Role in Pediatric Psychosis?

CONTEXT: Human and animal studies have suggested an underlying inflammatory mechanism for a variety of neuropsychiatric disorders, including schizophrenia. To date, most available reports focused on adult patients. OBJECTIVE: We wished to test the hypothesis that the first psychotic episode in youth is associated with inflammation. PATIENTS: We studied patients admitted to a pediatric inpatient psychiatric unit. Patients (n=80) had new-onset psychosis diagnosed using DSM-IV TR criteria for Psychosis NOS, Schizophreniform Disorder or Schizoaffective Disorder. Patients were matched for age, race and gender with inpatient controls without psychosis within the same unit (n=66). We also compared these values to normal pediatric hematologic values. To study the role of inflammation in youth with psychosis, we collected serum samples of 28 children presenting with first-episode psychosis and compared their serum cytokine and S100B levels to eight healthy controls. MAIN OUTCOME MEASURES: In this study, we measured serum markers of systemic inflammation. RESULTS: Leukocyte counts revealed a statistically significant increase in absolute monocytes compared to patients without psychosis (0.61 ± 0.282 k/ml vs. 0.496 ± 0.14 k/ml; p<0.01) and lymphocytes (2.51 ± 0.84 k/ml vs. 2.24 ± 0.72 k/ml; p<0.05) in patients with psychosis. All other hematologic values were similar between the groups. In addition, psychosis was characterized by increased serum levels of S100B, a peripheral marker of blood-brain barrier (BBB) damage. Several inflammatory mediators (e.g., TNF-α, IL-1ß, IL-6, IL-5, IL-10, and IFN-γ) were elevated in children with psychosis. CONCLUSIONS: These results strongly support a link between systemic inflammation, blood-brain barrier disruption and first-episode psychosis in pediatric patients.

Managing weight gain as a side effect of antidepressant therapy.

Weight gain caused by antidepressant drugs is a major reason for patient noncompliance with treatment and poor treatment outcome. Knowing which drugs are more likely to cause weight gain in the short term and the long term is essential to any discussion with the patient about the risks vs the benefits of antidepressant therapy. Informing the patient up front about the chances of weight gain and what can be done if it occurs helps build a strong physician-patient relationship and promotes good treatment outcomes.

Talking to patients about St. John's wort.

St. John's wort, an unregulated herbal supplement widely used as a self-treatment for depression, can cause side effects and drug interactions. Physicians should ask their patients about use of over-the-counter products such as St. John's wort and discuss their use in a frank but nonjudgmental manner.

Heart disease and depression: don't ignore the relationship.

Evidence is mounting that depression is a risk factor for the development of cardiovascular disease and portends a worse outcome in cardiac patients. Depression can be easily diagnosed and safely treated in cardiac patients, but it is undertreated.

Recognizing, managing medical consequences of eating disorders in primary care.

Eating disorders can lead to serious health problems, and as in many other disorders, primary care physicians are on the front line. Problems that can arise from intentional malnutrition and from purging affect multiple organ systems. Treatment challenges include maximizing weight gain while avoiding the refeeding syndrome.

Is an adult with Asperger syndrome sitting in your waiting room?

The prevalence of Asperger syndrome, a mild form of autism, appears to be rapidly increasing. This developmental disorder affects children and adults and can present challenges to providing medical care. In this update on Asperger syndrome, we offer guidance on how to interact with adult patients with the disorder. We also address proposed diagnostic changes scheduled to take effect in 2013.