Search

Robust screening measures that perform well in different populations could help improve the accuracy of diagnosis of pediatric bipolar disorder. Changes in sampling could influence the performance of items and potentially influence total scores enough to alter the predictive utility of scores. Additionally, creating a brief version of a measure by extracting items from a longer scale might cause differential functioning due to context effects. The authors of current study examined both sampling and context effects of a brief measure of pediatric mania. Caregivers of 813 youths completed the parent-reported version of the General Behavior Inventory (PGBI) at an academic medical center sample enriched for mood disorders. Caregivers of 481 youths completed the PGBI at a community mental health center. Caregivers of 799 youths completed 10 items extracted from the PGBI at a community setting. Caregivers of 159 youths completed both versions of the PGBI and a semistructured diagnostic interview. Differential item functioning indicated that across samples some items functioned differently; however, total observed scores were similar across all levels of mania. Receiver operating characteristic analysis indicated that the 10 extracted items discriminated bipolar disorder from nonbipolar behavior as well as when the items were embedded within the full measure. Findings suggest that the extracted items perform similarly to the embedded items in the community setting. Measurement properties appear sufficiently robust across settings to support clinical applications. (Contains 2 figures and 4 tables.)

Our goals in this article were to use item response theory (IRT) to assess the relation of depressive symptoms to the underlying dimension of depression and to demonstrate how IRT-based measurement strategies can yield more reliable data about depression severity than conventional symptom counts. Participants were 3,403 children and adolescents from 12 contributing clinical and nonclinical samples; all participants had received the Kiddie Schedule of Affective Disorders and Schizophrenia for School-Aged Children. Results revealed that some symptoms reflected higher levels of depression and were more discriminating than others. Furthermore, use of IRT-based information about symptom severity and discriminability in the measurement of depression severity was shown to reduce measurement error and increase measurement fidelity. (Contains 5 footnotes, 6 tables, and 6 figures.)

Objective: To examine lisdexamfetamine dimesylate (LDX) efficacy and safety versus placebo in adolescents with attention-deficit/hyperactivity disorder (ADHD). Method: Adolescents (13 through 17) with at least moderately symptomatic ADHD (ADHD Rating Scale IV: Clinician Version [ADHD-RS-IV] score greater than or equal to 28) were randomized to placebo or LDX (30, 50, or 70 mg/d) in a 4-week, forced-dose titration, double-blind study. Primary and secondary efficacy measures were the ADHD-RS-IV, Clinical Global Impressions-Improvement (CGI-I), and Youth QOL--Research Version (YQOL-R). Safety assessments included treatment-emergent adverse events (TEAEs), vital signs, laboratory findings, physical examinations, and ECG. Results: Overall, 314 participants were randomized; 309 were in efficacy analyses and 49 withdrew (11 due to TEAEs). Least squares mean (SE) change from baseline at endpoint in ADHD-RS-IV total scores were -18.3 (1.25), -21.1 (1.28), -20.7 (1.25) for 30, 50, and 70 mg/d LDX, respectively; -12.8 (1.25) for placebo (p less than or equal to 0.0056 versus placebo for each). Differences in ADHD-RS-IV total scores favored all LDX doses versus placebo at all weeks (p less than or equal to 0.0076). On the CGI-I, 69.1% of participants were rated very much/much improved at endpoint with LDX all doses versus placebo (39.5%) (p less than 0.0001). YQOL-R changes at endpoint scores for LDX groups versus placebo were not significant. Commonly reported LDX (all doses combined) TEAEs (greater than or equal to 5%) were decreased appetite, headache, insomnia, decreased weight, and irritability. Small mean increases in pulse and blood pressure and no clinically meaningful trends in ECG changes were noted with LDX. Conclusions: LDX at all doses was effective versus placebo in treating adolescent ADHD and demonstrated a safety profile consistent with previous LDX studies. (Contains 3 tables and 2 figures.)

ADHD is one of the most common neurobehavioral disorders of childhood, and FDA-approved medications offer an efficacious treatment option. However, case reports and anecdotal sources suggest that children can have emotional responses, both salutary and detrimental, to these agents. We have previously conducted a comprehensive literature review and found very few research studies systematically examining changes in emotional expression (EE) associated with ADHD medication use. In addition, no empirical data pertaining to the management of these responses could be found. Although few methodologically stringent data are available for changes in EE, such changes should be recognized and measured to determine appropriate responses by clinicians and to maximize treatment benefits and reduce side effects. In this companion report, we draw on available research evidence and clinical experience to explore typical clinical manifestations, differential diagnosis, scales for monitoring, and management approaches of EE observed with pharmacologic treatment of ADHD. In the future, controlled clinical trials of ADHD pharmacotherapy should employ standardized ratings of EE at baseline, during and after treatment. In addition, future research studies should examine various management approaches of these EE changes, to ensure maximal treatment benefits and minimal risks to patients with ADHD who are treated with medication. (Contains 2 tables and 1 figure.) [For Part I, see EJ913767.]

Objective: To examine the long-term safety and efficacy of three antipsychotics in early-onset schizophrenia spectrum disorders. Method: Patients (8 to 19 years old) who had improved during an 8-week, randomized, double-blind acute trial of olanzapine, risperidone, or molindone (plus benztropine) were eligible to continue on the same medication for up to 44 additional weeks under double-blind conditions. Adjunctive medications were allowed according to defined algorithms. Standardized symptom, safety, and functional assessments were conducted every 4 weeks. Results: Of the 116 youths randomized in the acute trial, 54 entered maintenance treatment (molindone, n = 20; olanzapine, n = 13; risperidone, n = 21). Fourteen (26%) completed 44 weeks of treatment. Adverse effects (n = 15), inadequate efficacy (n = 14), or study nonadherence (n = 8) were the most common reasons for discontinuation. The three treatment arms did not significantly differ in symptom decrease or time to discontinuation. Akathisia was more common with molindone and elevated prolactin concentrations more common with risperidone. Although weight gain and metabolic adverse events had occurred more often with olanzapine and risperidone during the acute trial, no significant between-drug differences emerged in most of these parameters during maintenance treatment. Conclusions: Only 12% of youths with early-onset schizophrenia spectrum disorders continued on their originally randomized treatment at 52 weeks. No agent demonstrated superior efficacy, and all were associated with side effects, including weight gain. Improved treatments are needed for early-onset schizophrenia spectrum disorders. Clinical trial registry information--Treatment of Schizophrenia and Related Disorders in Children and Adolescents; URL: "http://www.clinicaltrials.gov", unique identifier: NCT00053703. (Contains 2 figures and 6 tables.)

Adolescents are routinely treated with psychiatric medications; however, little is known about their attitudes toward pharmacological intervention. The authors used a concurrent triangulation, mixed methods design to assess whether the Drug Attitude Inventory (DAI), developed for adults, is suitable for measuring adolescent attitudes toward psychiatric medications. Factor analytic techniques and qualitative data were used to investigate whether the instrument provides comprehensive measurement of medication-related constructs in adolescents. Findings suggest that the DAI contributes to knowledge of youth attitudes toward psychotropic treatment; however, limitations were uncovered by the mixed methods approach. This study enhances the measurement and mixed methods literature by showing how qualitative and quantitative techniques served as parallel data reduction strategies for examining an instrument's utility with a new population. (Contains 6 tables and 1 figure.)

Developmental disorders such as subaverage intelligence, pervasive developmental disorders, and genetic syndromes are frequently associated with comorbid attention-deficit/hyperactivity disorder (ADHD) or ADHD-like symptoms. While there are not pharmacological cures for these developmental disorders, coinciding ADHD and ADHD-like symptoms that contribute to difficulties in psychosocial functioning are frequently able to be addressed by pharmacotherapy. This article reviews what is known about the efficacy and tolerability of pharmacological interventions for the treatment of children and adolescents suffering from developmental disorders and comorbid ADHD/ADHD-like symptoms. (Contains 3 tables.)

Background: Despite the effectiveness of psychotropic treatment for alleviating symptoms of psychiatric disorders, youth adherence to psychotropic medication regimens is low. Adolescent adherence rates range from 10-80% (Swanson, 2003; Cromer & Tarnowski, 1989; Lloyd et al., 1998; Brown, Borden, and Clingerman, 1985; Sleator, 1985) depending on the population and medication studied. Youth with serious mental illness face increased potential for substance abuse, legal problems, suicide attempts, and completed suicide (Birmaher & Axelson, 2006). Nonadherence may increase the potential for negative outcomes. The Drug Attitude Inventory (DAI) was created to measure attitudes toward neuroleptics and to predict adherence in adults (Hogan, Awad, & Eastwood, 1983). No studies have been identified that have used this instrument in adolescent psychiatric populations. The present study was undertaken to evaluate the utility of the DAI for measuring medication attitudes and predicting adherence in adolescents diagnosed with mental health disorders. Method: Structural equation modeling was used to compare the factor structure of the DAI in adults with its factor structure in adolescents. The relationship between adolescent DAI scores and adherence was examined also. Results: The adult factor structure demonstrated only "fair" fit to the adolescent data (RMSEA = 0.061). Results indicated a low, but significant positive correlation (r = 0.205, p less than 0.05) between DAI scores and adherence. Conclusions: Lack of optimal model fit suggests that DAI items may require alteration to reflect adolescent experiences with psychiatric medication more accurately. Differences between adolescents and adults in developmental stage, symptom chronicity, diagnosis, and medication class may explain why the adult model demonstrated only "fair fit" to the adolescent data and why the correlation between DAI scores and adherence was low. The DAI may be improved for use with adolescents by creating items reflecting autonomy concerns, diagnostic characteristics, treatment length, and side effect profiles relevant to adolescent experiences.

Objective: The aim was to evaluate in-office discussions of ADHD and psychiatric comorbidities. Method: Naturally occurring interactions among 11 psychiatrists, 32 patients and their parents were recorded, with a focus on "complicated" patients (i.e., having or suspected to have [greater than or equal to] 1 psychiatric comorbidities and/or learning disabilities in addition to ADHD). Participants were interviewed separately post visit. Transcripts were analyzed using validated sociolinguistic methodologies. Results: Some 62% of patients were male, with an average age of 12.5 years, and 79% had a family history of ADHD. Visits were psychiatrist-driven, focusing on medication management and school performance, leaving management of comorbidities largely unaddressed. Post visit, 78% of parents and psychiatrists disagreed on patients' "most concerning behavior." Parents most often reported concern about aggression and oppositionality. Psychiatrists and parents emphasized different aspects of patients' personality, using deficit- and strength-based models, respectively. Conclusion: Psychiatrists and parents interpreted the relationship between ADHD and comorbidities differently. The significant incidence of misalignment regarding worrisome behaviors warrants further exploration. (Contains 4 tables, 1 figure and 1 note.)

The short-term efficacy of methylphenidate in the treatment of youths aged 5 to 17 years with bipolar disorder (BD) and comorbid attention deficit/hyperactivity disorder (ADHD) was investigated. The trial observation showed that euthymic youths with BD and ADHD might benefit from short-term concomitant treatment with methylphenidate.

Objective: The Treatment of Early Onset Schizophrenia Spectrum Disorders Study is a publicly funded clinical trial designed to compare the therapeutic benefits, safety, and tolerability of risperidone, olanzapine, and molindone in youths with early-onset schizophrenia spectrum disorders. The rationale, design, and methods of the Treatment of Early Onset Schizophrenia Spectrum Disorders Study are described. Method: Using a randomized, double-blind, parallel-group design at four sites, youths with EOSS (ages 8-19 years) were assigned to an 8-week acute trial of risperidone (0.5-6.0 mg/day), olanzapine (2.5-20 mg/day), or molindone (10-140 mg/day). Responders continued double-blind treatment for 44 weeks. The primary outcome measure was responder status at 8 weeks, defined by a 20% reduction in baseline Positive and Negative Symptom Scale scores plus ratings of significant improvement on the Clinical Global Impressions. Secondary outcome measures included assessments of psychopathology, functional impairment, quality of life, and medication safety. An intent-to-treat analytic plan was used. Results: From February 2002 to May 2006, 476 youths were screened, 173 were further evaluated, and 119 were randomized. Several significant study modifications were required to address safety, the use of adjunctive medications, and the termination of the olanzapine treatment arm due to weight gain. Conclusions: The Treatment of Early Onset Schizophrenia Spectrum Disorders Study will inform clinical practice regarding the use of antipsychotic medications for youths with early-onset schizophrenia spectrum disorders. Important safety concerns emerged during the study, including higher than anticipated rates of suicidality and problems tapering thymoleptic agents before randomization. (Contains 4 tables.)

Objective: We examined baseline demographic and clinical profiles of youths enrolled from 2001 to 2006 in the publicly funded multicenter, randomized controlled trial Treatment of Early-Onset Schizophrenia Spectrum Disorders. Method: Youths (8-19 years) with schizophrenia (SZ) and schizoaffective disorder were recruited at four academic sites. Diagnosis was made via structured and clinical interviews. Assessments of psychiatric symptoms and social and global functioning were included. Results: A total of 119 youths were enrolled. The mean age at illness onset was 11.1 plus or minus 3.5 years. Patients with SZ and schizoaffective disorder had similar ratings on the Positive and Negative Symptom Scale, Brief Psychiatric Rating Scale for Children, and Clinical Global Impression-Severity Scale. The overall level of functioning was similar in the two groups. A comparison to published reports of adults with SZ indicates that these youths may have more severe symptoms based on results of the Positive and Negative Symptom Scale. Conclusions: This is one of the largest samples of youths with SZ spectrum disorders studied to date and the largest assessment of youths with schizoaffective disorder. High rates of symptoms and general psychopathology were noted. There was a substantial degree of social and functional impairment. The symptom profiles are consistent with, but more severe than, those reported in the adult literature. (Contains 3 tables and 2 figures.)

A 9-year-old boy presents for assessment and treatment of his reactive, impulsive aggressive behavior that has been present for approximately 2 years. Six months ago, his pediatrician started treatment with OROS methylphenidate (MPH), which was titrated to 36 mg/day. There was moderate improvement in symptoms of attention-deficit/hyperactivity disorder (ADHD) but minimal improvement in his aggression. His parents have been reasonably compliant with behavioral therapy for the past 2 months, but improvement in physical aggression has been limited. Last week he struck and injured a peer who cut in front of him in line. This was his third incident of aggressive behavior in school this year, leading to a 1-week suspension from school. On interview, he meets criteria for ADHD, combined subtype, and oppositional defiant disorder (ODD). There is no evidence of a mood, anxiety, substance use, or psychotic disorder. This article presents the opinions of five doctors on how they would handle this case vignette pharmacologically.

Objective: The safety, efficacy, and tolerability of venlafaxine extended release (ER) in subjects ages 7 to 17 years with major depressive disorder were evaluated in two multicenter, randomized, double-blind, placebo-controlled trials conducted between October 1997 and August 2001. Method: Participants received venlafaxine ER (flexible dose, based on body weight; intent to treat, n = 169) or placebo (intent to treat, n = 165) for up to 8 weeks. The primary efficacy variable was the change from baseline in the Children's Depression Rating Scale-Revised score at week 8. Results: There were no statistically significant differences between venlafaxine ER and placebo on the Children's Depression Rating Scale-Revised in either study. A post hoc age subgroup analysis of the pooled data showed greater improvement on the Children's Depression Rating Scale-Revised with venlafaxine ER than with placebo (-24.4 versus -19.9; p = 0.022) among adolescents (ages 12-17), but not among children (ages 7-11). The most common adverse events were anorexia and abdominal pain. Hostility and suicide-related events were more common in venlafaxine ER-treated participants than in placebo-treated participants. There were no completed suicides. Conclusions: Venlafaxine ER may be effective in depressed adolescents. However, its safety and efficacy in pediatric patients has not been established. Prescribers should monitor for signs of suicidal ideation and hostility in pediatric patients taking venlafaxine ER. (Contains 2 tables and 3 figures.)

This article presents responses to the question of whether clozapine is ever appropriate to use in the pediatric population. Among others, Jean A. Frazier also agreed that clozapine is appropriate for use in the pediatric population. Clozapine has truly revolutionized the treatment of refractory patients with schizophrenia at any age. This agent was approved by the U.S. Food and Drug Administration (FDA) in 1989 for use in individuals ages 18 years or older with treatment refractory schizophrenia. Subsequent to clozapine, the FDA has approved a number of atypical antipsychotics for the treatment of psychotic disorders, but none to date are approved for use in children and adolescents. Despite the superior efficacy of clozapine, its use has been limited because of its complex side effect profile, consisting of hypersalivation, weight gain, metabolic abnormalities, cardiovascular side effects, sedation, seizures, and agranulocytosis. Children may be more prone to developing these side effects than adults because of developmental differences in the metabolism of this agent.

Objective: Developmental and subtype differences in behavioral assets and problems were examined in 318 children newly diagnosed with ADHD. Method: Three age groups were compared: 4 to 6.9 years (n = 95), 7 to 9.9 years (n = 136), and 10 to 15 years (n = 87); with two subtypes examined: inattentive (n = 151), and hyperactive/combined (n = 167). Data on assets and problems were obtained from parental questionnaires. Analyses were conducted for the assets and problems data with subtype and age as between group factors. Results: Younger children had more problems with hyperactivity, and the eldest group had more externalizing problems. The hyperactive/combined subtype exhibited more problems than the inattentive subtype. Also the younger group had more assets than the eldest group. Conclusion: Children who possessed greater assets had fewer behavioral problems, with assessment of assets and problems important in the diagnosis of ADHD. (Contains 7 tables.)

Objective: To provide an initial description of the effectiveness and pharmacokinetics (PK) of quetiapine in aggressive children with conduct disorder (CD). Method: This 8-week, open-label outpatient trial, enrolled patients ages 6 to 12 years with CD. Outcome measures included the Rating of Aggression Against People and/or Property Scale (RAAPPS), Nisonger Child Behavior Rating Form (NCBRF), and the Conners Parent Rating Scale (CPRS-48). Blood sampling for PK analyses occurred at the end of weeks 2 and 8. Results: Seventeen children (16 boys, mean age 8.9 years) were treated. The mean dose at week 8 was 4.4 mg/kg (SD = 1.1 mg/kg). Significant decreases in the baseline scores of the RAAPPS, and several subscales of the NCBRF and the CPRS were found by the end of the study (p less than 0.05). No patients discontinued because of an adverse event. No patients experienced extrapyramidal side effects. Quetiapine disposition was linear over the dose range studied. The elimination half-life of the drug averaged 3.9 and 2.9 hours and total body clearance averaged 3.5 and 3.0 L/hr/kg after study weeks 2 and 8, respectively. Conclusions: These preliminary data suggest that aggressive children with CD may benefit from quetiapine. The PK of quetiapine supports twice-daily dosing in children with CD. (Contains 2 figures and 3 tables.)

Objective: Escitalopram is a selective serotonin reuptake inhibitor antidepressant indicated for use in adults. This trial examined the efficacy and safety of escitalopram in pediatric depression. Method: Patients (6-17 years old) with major depressive disorder were randomized to receive 8 weeks of double-blind flexibly dosed treatment with escitalopram (10-20 mg/day; n = 131) or placebo (n = 133). Randomization was not stratified by age. The primary efficacy measure was the mean change from baseline to endpoint in Children's Depression Rating Scale-Revised (CDRS-R) scores, using the last observation carried forward approach. Results: A total of 82% of patients completed treatment. Escitalopram did not significantly improve CDRS-R scores compared to placebo at endpoint (least squares mean difference = -1.7, p = 0.31; last observation carried forward). In a post hoc analysis of adolescent (ages 12-17 years) completers, escitalopram significantly improved CDRS-R scores compared with placebo (least squares mean difference = -4.6, p = 0.047). Headache and abdominal pain were the only adverse events in greater than 10% of patients in the escitalopram group. Discontinuation rates caused by adverse events were 1.5% for both groups. Potential suicide-related events were observed in one escitalopram- and two placebo treated patients. There were no completed suicides. Conclusions: Although there were no significant differences between escitalopram and placebo in the total population, the data suggest that escitalopram may have beneficial effects in adolescent patients. Escitalopram appeared to be well tolerated. (Contains 3 figures and 4 tables.)

Objective: It has been reported that bipolar disorder may become less responsive to previously effective treatment with each symptomatic relapse. The primary goal of this study was to assess the rate of restabilization after the resumption of lithium ([Li[superscript +]) plus divalproex (DVPX) following relapse on either agent as monotherapy. Method: This is a prospective, 8-week, open-label outpatient [Li[superscript +]/DVPX combination therapy trial. Patients ages 5 to 17 years with bipolar disorder type I or II, who had achieved symptom remission with [Li[superscript +]/DVPX combination therapy and subsequently relapsed during treatment with [Li[superscript +] or DVPX monotherapy were enrolled between January 1999 and January 2003 Results: Thirty-eight patients with a mean age of 10.5 years entered the study. Thirty-four (89.5%) patients responded to treatment with [Li[superscript +]/DVPX mood stabilizer therapy alone, but four patients required adjunctive antipsychotic treatment to address residual symptomatology. Overall, reinitiation of [Li[superscript +]/DVPX combination therapy was well tolerated with no subjects discontinuing because of a medication-related adverse event. Conclusions: It appears that most youths with bipolar disorder who stabilize on combination [Li[superscript +]/DVPX therapy and subsequently relapse during monotherapy can safely and effectively be restabilized with the reinitiation of [Li[superscript +]/DVPX combination treatment. (Contains 2 figures and 4 tables.)

This article provides an "autism vignette" and then poses an evaluative question to several autism specialists, documenting their varied responses to the scenario and question posed. A 13-year-old boy with autism and severe mental retardation presented to the inpatient psychiatric unit due to a recent increase in agitation and physical aggression. Following the closure of his group home, he moved to a similar one. He has not adjusted well to the changes in setting and staff. A behavioral specialist began working with the patient and the group home staff to address his increased pacing, anger outbursts, and minor physical aggression. When he struck a staff member, he was transported to the emergency department and psychiatrically hospitalized. Current medications include paroxetine 20 mg each morning, divalproex sodium 250 mg twice daily, and quetiapine 50 mg twice daily. The physicians are asked how they would address this scenario pharmacologically. The documented responses in this article are given by: Robert L. Findling, M.D.; Christopher J. McDougle, M.D.; Lawrence Scahill, M.S.N., Ph.D.; and Stephanie Hamarman, M.D.

This article outlines a provisional evidence-based approach to the assessment of pediatric bipolar disorder (PBD). Public attention to PBD and the rate of diagnosis have both increased substantially in the past decade. Accurate diagnosis is crucial to avoid harm due to mislabeling or unnecessary medication exposure. Because there are no proven efficacious or effective treatments for PBD, the role of assessment is heightened to demonstrate efficacy in individual cases as well as to identify cases for participation in clinical trials. This review discusses (a) the state of psychopathology research regarding PBD; (b) the likely base rate of PBD in multiple clinical settings; (c) the diagnostic value of family history; (d) challenges to differential diagnosis, including comorbidity and symptom overlap with other diagnoses, shortcomings in contemporary assessment methods, and the cyclical nature of PBD; (e) practical methods for improving diagnosis, focusing on the most discriminative symptoms, extending the temporal window of assessment to capture mood changes, and using screening tools within an actuarial framework; and (f) monitoring response to treatment using a variety of assessment methods. Twelve recommendations are offered to move toward an evidence-based assessment model for PBD.

Objective: To assess the efficacy of topiramate monotherapy for acute mania in children and adolescents with bipolar disorder type 1. Method: This double-blind, placebo-controlled study was discontinued early when adult mania trials with topiramate failed to show efficacy. Efficacy end points included the Young Mania Rating Scale (YMRS), Brief Psychiatric Rating Scale for Children, Children's Depression Rating Scale, Children's Global Assessment Scale, and Clinical Global Impressions-Improvement. Results: Fifty-six children and adolescents (6-17 years) with a diagnosis of bipolar disorder type I received topiramate (n = 29, 52%) or placebo (n = 27, 48%). The only statistically significant differences in efficacy measures between treatment groups were the difference between slopes of the linear mean profiles of the YMRS (p = .003) using a post hoc repeated measures regression and the change in Brief Psychiatric Rating Scale for Children at day 28 (-14.9 versus -.9, p = .048) using observed data. Adverse events with topiramate included decreased appetite, nausea, diarrhea, and paresthesia. Conclusions: Topiramate was well tolerated; however, the results are inconclusive because of premature termination resulting in a limited sample size. Adequately powered controlled trials are necessary to determine whether topiramate has efficacy in reducing symptoms of acute mania in children and adolescents. J. Am. Acad. Child Adolesc. Psychiatry, 2005;44(6):539-547. Key Words: mania, bipolar disorder, topiramate.

Recent evidence from the Treatment for Adolescents With Depression Study (TADS) suggests that combining cognitive behavioral and pharmacological treatments holds the most promise for ameliorating depression among adolescents. This article describes lessons learned during the TADS trial about how to integrate these two treatments in the care of adolescents with depression. Toward this end, both common and unique components of each perspective's approach to data gathering and treatment selection are presented. Procedures for changing "dosage" and adding adjunctive treatments to each of these interventions are also discussed. Finally, issues related to sequencing treatments and guidelines for sharing information across treatment providers are offered.

Objective: To determine the long-term safety and effectiveness of risperidone for severe disruptive behaviors in children. Method: A multisite, 1-year, open-label study of patients aged 5 to 14 years with disruptive behaviors and subaverage intelligence was conducted. Results: Seventy-three percent of the 504 patients enrolled completed the study. The mean [+ or -] SE dose of risperidone was 1.6 [+ or -] 0.0 mg/day. The most common adverse events were somnolence (30%), rhinitis (27%), and headache (22%). The incidence of movement disorders was low, and mean Extrapyramidal Symptom Rating Scale scores decreased during risperidone treatment. No clinically significant changes in mean laboratory values were noted, except for a transient increase in serum prolactin levels. Scores on the Nisonger Child Behavior Rating Form Conduct Problem Scale improved significantly as early as early as week 1, and improvement was maintained throughout the trial (p Less than .001 at each time point). Significant improvements were noted on positive social behavior and other Nisonger Child Behavior Rating Form subscales, Aberrant Behavior Checklist, Clinical Global Impressions scale, and tests of patients' cognitive function (each p less than.001). Conclusions: Risperidone was well tolerated and effective in the long-term treatment of disruptive behavior disorders in children with subaverage intelligence.

Objective: To compare the diagnostic efficiency of six index tests as predictors of juvenile bipolar disorder in two large outpatient samples, aged 5 to 10 and 11 to 17 years, gathered from 1997 to 2002. Method: DSM-IV diagnosis was based on a semistructured diagnostic interview (Schedule for Affective Disorders and Schizophrenia for School-Age Children) with the parent and youth sequentially, blind to scores on the index tests. Participants were 318 youths aged 5 to 10 (50% with bipolar diagnoses) and 324 youths aged 11 to 17 (41% with bipolar diagnoses). Areas under the curve (AUCs) from receiver operating characteristic analyses and multilevel likelihood ratios quantified test performance. Results: Parent report (AUCs from 0.78 to 0.84 in both age groups) outperformed teacher (AUCs 0.57 in the younger sample and 0.70 in the older sample) or adolescent measures (AUCs 0.67 [General Behavior Inventory] and 0.71 [Youth Self-Report]) at identifying bipolar disorders. Combining tests did not produce clinically meaningful classification improvement. Conclusions: Parent report was more useful than teacher report or adolescent self-report on the index tests studied. Results generally replicated across both age groups. Parent report on these instruments could facilitate differential diagnosis of bipolar disorder in youths aged 5 to 17 years, especially by decreasing the rate of false-positive diagnoses.

Objective: The purpose of this study was to examine the efficacy of psychostimulant medication in a naturalistic sample of preschoolers. Benefits and side effects for methylphenidate and mixed amphetamine salts (Adderall) were examined. Method: Twenty-eight preschoolers (ages 4.0-5.9) participated in the present investigation. They were obtained consecutively from a large sample of suburban children assessed for attention-deficit/hyperactivity disorder. After having received various dosing levels of a stimulant in a placebo-controlled crossover design, best dose was assigned based on the lowest Abbreviated Symptoms Questionnaire T score received in a given week. All analyses compared best dose ratings to placebo ratings. Results: Preschoolers' behavioral ratings by parents and teachers were improved as a function of stimulant medication. More than 82% of the medicated sample improved their behavioral rating by at least 1 SD as demonstrated by receiver operating characteristic (ROC) analyses, with more than 50% of medicated preschoolers improving by more than 2 SD. Side effects were infrequent at best dose of medication. Conclusions: Clinically significant changes in behavioral ratings of preschoolers were noted in response to stimulant medication. Both stimulants were well tolerated. ROC curves were useful for clearly depicting on a case-by-case basis how much improvement was derived from psychopharmacological treatment.

Objective: To examine the effect of combined lithium and divalproex sodium on thyroid-stimulating hormone (TSH) levels in children and adolescents with bipolar disorders and to identify risk factors for lithium-induced hypothyroidism. Method: Bipolar youths aged 5 to 17 years participating in an open-label clinical trial received treatment with lithium and divalproex sodium for up to 20 weeks. TSH levels were measured at baseline and at the end of the study. Subjects were divided into two groups for analysis: group 1 had TSH levels of less than 10.0 mU/L at the end of the study and group 2 had TSH levels of 10.0 mU/L or more at end of the study. Results: Twenty of the 82 subjects (24.4%) showed TSH elevations of at least 10 mU/L within an average exposure of less than 3 months. The mean baseline TSH level for group 2 was significantly higher than for group 1 (2.97 [SD = 1.48] versus 2.05 [SD = 0.89], p < .05). Mean lithium levels at the end of the study were 1.00 mEq/L for group 2 compared to 0.76 mEq/L for group 1 (t = -2.41, p = .019). Conclusions: Lithium is associated with significant rates of thyrotropin elevation in bipolar youths. Factors associated with elevation in TSH in lithium-treated subjects include a higher baseline TSH level and a higher lithium level. Close monitoring of thyroid function in children and adolescents taking lithium is recommended.

Despite the severity of bipolar disorder (BP) and the amount of attention the psychosocial treatment of BP among adults has been given (e.g., Basco & Rush, 1996; Miklowitz, Frank, & George, 1996), no published outcome study or psychosocial treatment manual to date exists for children with this disorder. Based upon what is known about the phenomenology of BP in adolescents and what has been published with regard to existing treatments and their efficacy for adults with BP and adolescents with unipolar depression, the purpose of this article is to describe a model for an empirically driven cognitive behavioral treatment for BP in adolescents. The manualized intervention described herein includes the following intervention components: psychoeducation, medication compliance, mood monitoring, anticipating stressors and problem solving, identifying and modifying unhelpful thinking, sleep regulation and relaxation, and family communication. In addition, optional modules devoted to substance abuse, social skills, anger management, and contingency management are offered. The treatment includes a 12-session acute phase of treatment, followed by a maintenance phase and biyearly "booster" sessions. The rationale for and format of each session is presented. Currently, a pilot study is under way to evaluate the preliminary efficacy of this treatment for adolescents with BP. To illustrate the treatment, we present a case study including outcome data for a 13-year-old boy with bipolar I.