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Antipsychotic drugs are used to treat a wide variety of child psychiatric disorders characterized by psychotic symptoms, aggression, excitement, tics, stereotypies and hyperactivity nonresponsive to other therapies. Unfortunately, typical antipsychotics have many adverse effects limiting their long-term use. Novel antipsychotics with combined dopaminergic and serotonergic action, such as risperidone, appear to offer better safety and efficacy profiles in controlled studies of adult patients, and therefore appeared as promising pharmacotherapeutic agents in child psychiatry. The purpose of this retrospective chart review was to obtain data on the potential effectiveness and tolerability of risperidone in children and adolescents presenting with a variety of chronic and severe psychiatric disorders who had been unresponsive to previous pharmacological treatments. Charts for 106 children and adolescents (males n = 81 or 76.4%; females n = 25 or 23.6%), presenting with attention deficit and/or hyperactivity disorder (n = 49 or 46.2%), conduct disorder (n = 13 or 12.3%), oppositional-defiant disorder (n = 5 or 4.7%), behavioural problems not otherwise specified (n = 2 or 1.9%), autism (n = 8 or 7.5%), Asperger's syndrome (n = 8 or 7.5%), pervasive developmental disorder (PDD) not otherwise specified (n = 4 or 3.8%), anxiety (n = 6 or 5.7%), depression (n = 2 or 1.9%), dysthymia (n = 2 or 1.9%), schizophrenia (n = 4 or 3.8%), adjustment disorder (n = 1 or 0.9%) and obsessive-compulsive disorder (n = 2 or 1.9%) were reviewed retrospectively to determine the tolerability and potential efficacy of risperidone treatment for a variety of psychiatric disorders. Six subjects also presented with mental retardation. The average length of illness prior to risperidone treatment was 5 years and the average age of risperidone treatment onset was 11 years. The mean daily dose of risperidone was 1.2 mg (range = 0.25 to 8.0 mg). Very few adverse effects were reported. The average length of risperidone treatment was 11 months with the majority (n = 75 or 76%) of patients maintained on risperidone following study termination. Seven cases (6.6%) were missing follow-up data. The majority (n = 78 or 74%) of patients were taking concurrent psychiatric medications, most commonly stimulants for the treatment of ADHD. Clinical global improvements for children and adolescents at the final study visit were marked (n = .37 or 34.9%), moderate (n = .40 or 37.7%), mild (n = 13 or 12.4%), none (n = 12 or 11.3%), or worse (n = 1 or 1%). Three cases (2.9%) were missing clinical improvement data. Results suggest that risperidone may be useful for managing behavioural disturbances and psychotic symptoms associated with a wide variety of childhood psychiatric disorders. For most patients in the study, a combination of risperidone and adjunctive pharmacotherapy was beneficial. Controlled and discontinuation studies of risperidone treatment in children and adolescents with behavioural and psychotic disorders are recommended.
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PMID:A retrospective chart review of risperidone use in treatment-resistant children and adolescents with psychiatric disorders. 1181 3

Compared 2 groups of children with attention deficit hyperactivity disorder, predominantly inattentive type (ADHD/IA)--those with high scores on a composite measure of sluggish cognitive tempo (SCT) and those without--using a large, school-based sample of children for which previous comparisons between ADHD subtypes have been reported. Although the 2 groups did not differ on level of attention or learning problems, high-SCT ADHD/IA children were rated by teachers as showing less externalizing behavior and higher levels of unhappiness, anxiety/depression, withdrawn behavior, and social dysfunction. Thus, SCT identifies a more homogeneous subgroup of ADHD/IA children who are, relative to the entire Diagnostic and Statistical Manual of Mental Disorders (4th ed. [DSM-IV]; American Psychiatric Association [APA], 1994) diagnosed ADHD/IA group, more similar to those classified in previous research as "attention deficit disorder without hyperactivity." These results support a reconsideration of SCT symptoms as a component of diagnostic criteria for a category of nonhyperactive attention deficit disorder.
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PMID:Sluggish cognitive tempo predicts a different pattern of impairment in the attention deficit hyperactivity disorder, predominantly inattentive type. 1184 44

It is imperative to know what risk factors are more likely to appear during specific developmental stages so that identification and interventions can be used to decrease the risk for future SUD. Continued surveying of risk factors that can occur at any stage in childhood are important to ensure that other risk factors are anticipated and intervened upon as well. Multiple risk factors increase the magnitude of the risk for SUD, and therefore all risk factors should be detected to convert these to protective factors. Screening instruments that can assess risk factors found to increase the risk for substance abuse can be found in examples, such as the Drug Usage Screening Instrument [81] and the Problem-Oriented Screening Instrument for Teenagers. The detection of risk factors by primary care providers is becoming increasingly important. However, other professionals are beginning to recognize that early recognition and treatment can enable a youth to go on to a productive life in other arenas as well. Drug courts and diversion programs are beginning to treat first-time offenders and their families rather than taking the punitive approach. These have proven to be very successful. Primary care physicians also should become familiar with motivational enhancement therapy when confronting a youth with a suspected substance abuse problem [57]. This method has proven to be more effective in getting youth into treatment than the direct, confrontational style, which often puts the youth in a defensive mode. Motivational enhancement therapy includes interventions that are delivered in a neutral and empathetic way. The six components of motivational enhancement therapy (also called FRAMES) include: Feedback on personal impairment Emphasis on personal responsibility Clear advice to change Menu of alternative options Empathy as a counseling style Self-efficacy In this way, a clinician can elicit pros and cons, give advice, provide choices, practice empathy, clarify goals, and remove barriers. This technique allows youth to be less defensive and more proactive. Monti et al. [59] have demonstrated that this technique has been useful in getting youth into treatment. Primary care physicians can use instruments that will assess the possibility of both externalizing (e.g., ADHD) and internalizing (e.g., depression and anxiety) disorders. Examples of this type of instrument are the Auchenbach child behavior checklist, teacher report form, and youth self-report form, which survey symptoms for these disorders [1]. Social anxiety disorder can be detected by asking whether the prelatency child went into new situations willingly and tended to hang back or whether the child had difficulty separating from his or her parents. Other questions to ask are whether the child tended to isolate or was fearful of speaking in front of the class. Of course, any bruising or behavior that suggests exposure to adult-related sexual acts may cause concern for physical or sexual abuse and possible PTSD. However, interest in sex earlier than expected for the age of the child may also indicate the possibility of bipolar disorder. These children have many symptoms of ADHD with a high degree of irritability and may seem boastful or grandiose. They may be "daredevils" with no fear of dangerous consequences. Referral to a specialist is necessary to evaluate these children further. Because substance use at age 14 or 15 years can be predicted by academic and social behavior at ages 7 to 9 years, early detection of poor social skills and learning difficulties is essential [43]. Learning disorders can be uncovered by asking the school to do an evaluation. However, schools having economic problems may not be able to accommodate all requests. A parent may have to pay a private provider to complete this workup because insurance companies seldom pay for educational testing. Learning disorders may go undetected because many school systems opt to use a higher deviation from the full-scale IQ to detect learning problems. For instance, if a student has an IQ of 115, the standard nationally recommended deviation from this IQ to detect a learning disorder is 15. Therefore, any child who scores 100 or less on an achievement test should be considered to have a learning disorder. Some schools prefer to use a deviation of up to 23 so that learning disorders are not detected. Few schools screen for processing problems, including auditory and visual motor processing problems, processing speed, comprehension, and short-term and long-term memory problems. This is extremely important because ADHD can be confused with an auditory processing problem. Stimulants may help this condition, but accommodations must be made to ensure continued success. Early-intervention programs, such as Drug Abuse Resistance Education (DARE), proved to be ineffective because the programs did not target components that have been shown to predict future drug use [54]. One program that has targeted these components, normative beliefs, lifestyle-behavior incongruence, and commitment is the All Stars program [39,40]. A strong initial dosage with booster interventions for at least 2 years is also important [10]. Before a child is diagnosed with oppositional defiant disorder or conduct disorder, every effort should be made to detect any underlying psychiatric disorder that has not been treated and therefore may look like a conduct disorder (e.g., bipolar disorder). Proper psychopharmacologic interventions should be made for psychiatric disorders. If one drug has been ineffective, another untreated psychiatric disorder may be present, and it is always important to tease out what remaining symptoms are present after a therapeutic trial has been tried. It is important to form a team approach so that all risk factors can be approached. Members of the team often include a primary care physician, a child psychologist, the parents, the patient, a teacher, a school counselor, a child psychiatrist, and sometimes a pediatric neurologist. No one member of the treatment team can provide all of the necessary services to prevent the future risk for substance abuse.
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PMID:Adolescent substance use disorders and comorbidity. 1199 93

Youth with severe emotional and behavioral disorders (EBD) were randomly assigned for 3 months of intensive treatment to a 5-day residential program (5DR Program) or a community-based alternative, family preservation program (FP Program). Programs differed not only in method of service delivery (residential unit vs. home-based), but also in treatment philosophy (solution focused brief therapy vs. cognitive behavioral). Results confirmed high rates of comorbidity in this population for externalizing and internalizing disorders. A significant Treatment x Program interaction was evident for internalizing disorders. At 1-year follow-up, significantly higher percentages of youth from the FP Program revealed a reduction of clinical symptoms for ADHD, as well as, general anxiety and depression, whereas significant proportion of youth from the 5DR Program demonstrated clinical deterioration and increased symptoms of anxiety and depression. Results have implications for future treatment of youth with EBD and suggest that greater emphasis be placed on research linking treatment to specific symptom clusters, especially highly comorbid clusters in this hard to serve population.
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PMID:Treatment programs for youth with emotional and behavioral disorders: an outcome study of two alternate approaches. 1209 Mar 10

We investigated the Depression-->Distortion hypothesis by examining the effects of maternal depressive symptoms on cross-informant discrepancies in reports of child behavior problems and several measures of parent-child relationship. The sample included ninety-six 6 to 10-year-old children diagnosed with ADHD-Combined Type, and their mothers, who provided baseline data before participating in a randomized clinical trial. Measures incorporated child characteristics, self-reports of maternal depressive symptoms, parenting practices, and laboratory mother-child interactions. Elevations in maternal depressive symptoms were associated with maternal reports of negative parenting style but not with observed laboratory interactions. Mothers' levels of depressive symptoms predicted negative biases in their reports of their child's ADHD symptoms, general behavior problems, and their own negative parenting style. Whereas levels of depressive symptoms did not predict observed parenting behaviors, maternal distortions did predict problemaTic parent-child interactions. Exploratory analyses showed a marginally significant mediation effect of the relationship between maternal depressive symptomatology and reports of negative parenting by depressive distortions. We discuss implications of linkages between depressive symptoms in mothers, depression-related distortions, and mother-child relationships for research and intervention in developmental psychopathology.
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PMID:Mother-child relationships of children with ADHD: the role of maternal depressive symptoms and depression-related distortions. 1210 89

Mothers of children with Attention-Deficit/Hyperactivity Disorder face an increased risk for depression, anxiety, and social isolation. In addition to stress due to children's behavior, mothers of children with ADHD may also feel stigmatized by their children's diagnosis. Fifty-one mothers participated in a study to assess attitudes toward ADHD. Although mothers of children with ADHD expected that parents of children without ADHD would hold harsh views of the disorder, this was not generally the case. This difference between perception and the actual self-reported views of mothers of children without ADHD supports the idea that mothers feel stigmatized but suggests that increased awareness might help mothers of children with ADHD feel less isolated.
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PMID:Courtesy stigma in mothers of children with Attention-Deficit/Hyperactivity Disorder: a preliminary investigation. 1214 62

The Beck Depression Inventory-II (BDI-II; Beck, Steer, & Brown, 1996) and the Conners' Adult ADHD Rating Scale-Self-Report: Screening Version (CAARS-S:SV; Conners, Erhardt, & Sparrow, 1999) were administered to 371 (64%) female and 204 (36%) male adult (> 18 years old) outpatients who were diagnosed with various psychiatric disorders to determine whether any of the 21 items or subsets of items in the BDI-II were related to symptoms of attention deficits and hyperactivity as measured by the CAARS-S:SV DSM-IV Total ADHD Symptoms scale (attention-deficit/hyperactivity disorder [ADHD] Symptoms). Stepwise multiple-regression analyses found that the BDI-II Concentration Difficulty explained 30% of the variance in these total scores. Ratings > 1 for the BDI-II Concentration Difficulty item were discussed as being useful for ruling out possible symptoms of ADHD.
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PMID:Beck Depression Inventory-II items associated with self-reported symptoms of ADHD in adult psychiatric outpatients. 1258 68

Publications of Swedish child and adolescent psychiatric out-patients have been scarce. This study is aimed to give a picture of conditions in a child and adolescent psychiatric out-patient setting by reporting five-year data from a five-year cohort of first-time visits. All first-visits, 0-18 years of age, where screened retrospectively for background factors, symptoms, diagnoses and types of treatment. Six hundred and ten patients were registered during the period. The estimated accumulated prevalence for 19-year-olds were 19,7 %. Nearly half of them were seen 1-3 times. A small group, 2,5 %, accounted for about 20 % of all consultations. No or mild psychosocial stress was registered in 37 % of the cases. A neuropsychiatric main diagnosis was found for 27 % (2,1:1, boys:girls) and depression and anxiety for 20 % [0, 5:1] of the index-cases. These findings show that 5,6 % of children applied for child and adolescent psychiatric help during a five-year period. Almost one third had a neuropsychiatric disorder. The results indicate that ADHD is one of the most common causes both among boys and girls to seek help in a child and adolescent out-patient clinic.
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PMID:Swedish child and adolescent psychiatric out-patients--a five-year cohort. 1260 62

Posttraumatic stress disorder is a common cause of morbidity in children and adolescents. The disorder in youth is similar to that in adults, with high rates of psychiatric comorbidity. Children seem to be more sensitive to the effects of trauma, and early life trauma exposure may induce a complex sequence of events that leads to the development of multiple psychiatric disorders in adulthood. The state of knowledge regarding medication treatments for children and adolescents is in the earliest stages of development. There are no well-conducted, randomized clinical trials to guide practitioners. Medication may play an important role in reducing debilitating symptoms of PTSD and providing a buffer for children while they confront difficult material in therapy and may help to improve their general functioning in day-to-day life. Given the various medications with potential usefulness in PTSD, it is helpful to use a stepwise approach to treatment. As a general principal, broad-spectrum agents, such as the SSRIs, are a good first choice. The SSRIs have efficacy in treating the core symptoms of PTSD and conditions such as the anxiety disorders and depression that commonly co-occur with PTSD. These agents also improve social and occupational functioning and an individual's perception of improved quality of life [41, 45, 46]. Although the SSRIs are generally effective for a broad spectrum of problems, clinicians should systematically monitor for the persistence of symptoms that do not respond to these agents. For example, despite significant improvements in core PTSD symptoms in one study that used sertraline, little improvement was seen in patients' comorbid anxiety and depressive symptoms [41]. This finding demonstrates the value of continuous symptom monitoring and shows that residual or comorbid symptoms may require a different medication to augment effective SSRI treatment for PTSD. A reasonable approach is to begin with a broad-spectrum agent, such as an SSRI, which should target anxiety, mood, and reexperiencing symptoms. Adrenergic agents, such as clonidine, used either alone or in combination with an SSRI may be useful when symptoms of hyperarousal and impulsivity are problematic. Supplementing with a mood stabilizer may be necessary in severe affective dyscontrol. Similarly, introduction of an atypical neuroleptic agent may be necessary in cases of severe self-injurious behavior, dissociation, psychosis, or aggression. Comorbid conditions such as ADHD should be targeted with pharmacotherapy known to be effective, such as psychostimulants or newer agents such as atomoxetine. Pharmacologic treatment of PTSD in childhood is one approach to alleviating the acute and chronic symptoms of the disorder. Despite the lack of well-designed, randomized, controlled trials that support efficacy, medication can be used in a rational and safe manner. Reduction in even one disabling symptom, such as insomnia or hyperarousal, may have a positive ripple effect on a child's overall functioning. Pharmacotherapy is typically used as one component of a more comprehensive multiple modality treatment package, including psychoeducation of the parent and child, focused exposure-based psychotherapy with adjunctive family therapy when indicated, and long-term booster interventions that use an admixture of psychodynamic, cognitive-behavioral, and pharmacologic interventions.
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PMID:Pharmacologic treatment approaches for children and adolescents with posttraumatic stress disorder. 1272 11

We investigated a risk-resilience model in 91 girls with ADHD and 58 age- and ethnicity-equated comparison girls, who participated in all-female naturalistic summer research camps. The hypothesized risk factor was peer rejection (assessed via sociometric nominations), with criterion measures including multiinformant composites of aggressive behavior and anxious/depressed symptoms. The two hypothesized protective factors were the girls' popularity with adult staff (assessed via staff ratings) and objective observations of goal-directed solitary play. Peer rejection was related to higher levels of aggressive behavior and depressed/anxious behavior, confirming its status as a risk factor. Next, for all girls, popularity with adults predicted lower levels of aggression and goal-directed solitary play predicted lower levels of anxiety/depression. Whereas popularity with adults was most protective among the peer-accepted subgroup, solitary play was most protective among the peer-rejected subgroup. Diagnostic status (ADHD versus comparison) moderated the findings such that engaging in meaningful solitary play was a stronger predictor of lower levels of anxious/depressed behavior in girls with ADHD than in comparison girls. We discuss the need for replication in prospective research and implications for research and intervention regarding the social functioning of peer-rejected children, particularly those with behavior disorders.
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PMID:Buffers of peer rejection among girls with and without ADHD: the role of popularity with adults and goal-directed solitary play. 1283 Dec 28


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