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Objective: To conduct a 1-year follow-up of anxious-depressed school-refusing adolescents who participated in an 8-week study of imipramine versus placebo, each in combination with cognitive-behavioral therapy., Method: Sixty-five percent (41 of 63) of the randomly assigned subjects returned for follow-up evaluation, which consisted of diagnostic interviews, clinician rating scales for anxiety and depression, family functioning measure, and a questionnaire regarding interim treatments and school programs., Results: From the adolescent and/or parent perspective, 64.1% met criteria for an anxiety disorder and 33.3% met criteria for a depressive disorder. Remission rates and acquisition rates for specific anxiety and depressive disorders were determined. In the follow-up period, 67.5% received at least one psychotropic medication trial and 77.5% had outpatient therapy. Higher level of somatic complaints on the Anxiety Rating for Children-Revised Physiological subscale at baseline predicted more severe depression on the Children's Depression Rating Scale-Revised at follow-up (p = .029)., Conclusions: In this naturalistic follow-up study, there was high utilization of mental health interventions. In addition, a substantial number of subjects met criteria for anxiety and/or depressive disorders 1 year after treatment. Investigation of duration of acute treatments and evaluation of maintenance treatments for school refusal is needed.

A male adolescent presented with aggression, depressed mood, and severe movement disorder that developed at age 5 after exposure to neuroleptics. Evaluation revealed acanthocytes in his blood, which led to a differential diagnosis of tardive dyskinesia versus choreoacanthocytosis. However, this is unusually young age of onset for these conditions. Differential diagnosis, medication management of the movement disorder, and pathophysiological mechanisms in tardive dyskinesia and choreoacanthocytosis are discussed.

Objective: To investigate the efficacy of 8 weeks of imipramine versus placebo in combination with cognitive-behavioral therapy (CBT) for the treatment of school-refusing adolescents with comorbid anxiety and major depressive disorders., Method: This was a randomized, double-blind trial with 63 subjects entering the study and 47 completing. Outcome measures were weekly school attendance rates based on percentage of hours attended and anxiety and depression rating scales., Results: Over the course of treatment, school attendance improved significantly for the imipramine group (z = 4.36, p < .001) but not for the placebo group (z = 1.26, not significant). School attendance of the imipramine group improved at a significantly faster rate than did that of the placebo group (z = 2.39, p = .017). Over the 8 weeks of treatment, there was a significant difference between groups on attendance after controlling for baseline attendance; mean attendance rate in the final week was 70.1% +/- 30.6% for the imipramine group and 27.6% +/- 36.1% for the placebo group (p < .001). Defining remission as 75% school attendance, 54.2% of the imipramine group met this criterion after treatment compared with only 16.7% from the placebo group (p = .007). Anxiety and depression rating scales decreased significantly across treatment for both groups, with depression on the Children's Depression Rating Scale-Revised decreasing at a significantly faster rate in the imipramine group compared with the placebo group (z = 2.08, p = .037)., Conclusions: Imipramine plus CBT is significantly more efficacious than placebo plus CBT in improving school attendance and decreasing symptoms of depression in school-refusing adolescents with comorbid anxiety and depression.

Objective: To identify the most common physical complaints in a sample of adolescent school refusers with comorbid anxiety and depressive disorders. Whether somatic symptoms are more likely to be associated with high levels of anxiety or high levels of depression was also explored., Method: Forty-four adolescents in a treatment study were evaluated at baseline with structured psychiatric interviews and measures of anxiety, depression, and somatization., Results: The most common somatic complaints were in the autonomic and gastrointestinal categories. In simple regression analyses, anxiety level as measured with the Revised Children's Manifest Anxiety Scale and depression level as measured with the Beck Depression Inventory each significantly predicted the severity of somatic symptoms. The correlation between percentage of days absent from school and severity of somatic symptoms approached significance (r = .27, p = .074)., Conclusions: Knowledge that somatic complaints are commonly an expression of underlying anxiety and depression may facilitate more rapid referral for psychiatric assessment and treatment and thereby help avoid unnecessary medical workups and sequelae from school refusal.

Objective: To critically review the research on anxiety disorders in children and adolescents, focusing on new developments in the past 10 years., Method: This review includes recent articles which contribute to the conceptualization, assessment, and treatment of childhood anxiety disorders., Results: Information was organized into a developmental framework. Anxiety disorders research has shown steady progress., Conclusions: More research is needed, particularly in the areas of neurobiological basis of anxiety disorders, longitudinal studies, and treatment.

The association of depression and conduct disorder is common and often perplexing in child psychiatry. Using a systematic retrospective chart review, various symptom, demographic and family history variables were compared between depression with comorbid conduct disorder and depression alone. Variables which differed between groups were entered into a stepwise discriminative function analysis. The four variables which discriminated between groups were anxiety, witness to family violence, illegal behavior, and impulsive behavior. The strongest discriminating variable, anxiety, was associated with depression without comorbid conduct disorder. These results emphasize the heterogeneity of childhood depression and potential importance of anxiety.

This study is a comparison of symptoms between depressed inpatient pre-adolescents and adolescents. One hundred and eight hospital records were reviewed with a structured format and were assigned DSM-III-R (American Psychiatric Association, 1987) diagnoses. Twenty-two pre-adolescents and 34 adolescents had symptoms documented which satisfied criteria for major depression. These two groups were compared on demographic and symptom variables. The majority of variables studied did not differ between age groups. Of those which did, the most predictive of adolescence were melancholia, global improvement rating, and suicide attempts. Temper outbursts, distractibility, and irritability predicted the prepubertal age group.

As more pharmacologic treatment and research on child and adolescent psychiatric patients are conducted, the common problem of blood-drawing fears will need to be addressed. Avoidance of blood-drawing could jeopardize an individual's physical and mental health, and inhibit the collection of data aimed at furthering the study of psychiatric disorders in youth. This report describes the naturalistic application of specific techniques for managing severe blood-drawing fears in adolescent subjects undergoing a clinical trial. The adolescents (ages 12-18) were 44 consecutive school refusers with comorbid anxiety and major depressive disorders. Of the school-refusing adolescents, 27% (12 of 44) were observed to have a severe fear of blood-drawing. A management strategy comprised of providing information, distraction, supportive reassurance, and exposure appeared successful in managing the fears of blood-drawing in all of the adolescents, except two. These 2 adolescents refused to enter the treatment study due to a marked fear of blood-drawing. All 10 subjects who exhibited a fear of blood-drawing and were able to complete the initial blood test, using the interventions noted, were able to obtain subsequent venipunctures with minimal or no avoidance behavior. These preliminary findings suggest that blood-drawing fears can be effectively managed in most cases, though controlled studies of these interventions are needed.

The purpose of this study was to examine the rates of psychiatric disorders in the parents of affective disordered adolescent inpatients, and to examine characteristics of the adolescent patients' illnesses and hospital stays for effects of having a concurrently depressed mother. Twenty-three percent of the depressed probands (N = 33), 20% of the bipolar group (N = 10), and 9% of the psychiatric control group (N = 11) had mothers who reported major depression (MD) at the time of hospitalization. Concurrent maternal depression did not have prominent effects on the course of the adolescents' hospitalizations.

This study examined comorbid psychiatric disorders in adolescents with bipolar disorder. Hospitalized bipolar adolescents (N = 10) were compared to hospitalized adolescents with unipolar depression (N = 33), and to adolescents with nonaffective psychiatric disorders (N = 11). Results showed conduct disorder, attention-deficit hyperactivity disorder, psychosis, and having any DSM-III-R psychoactive substance use disorder were all significantly more common in the bipolar group than the unipolar depressed group. Comorbid anxiety disorder was present in 40-45% of the subjects in the unipolar and bipolar groups, but in none of the control group subjects.

This study describes children and adolescents with school refusal who were hospitalized and compares them to a matched group with school refusal who were treated as outpatients in order to examine the use of hospitalization in the treatment of this symptom presentation. The results showed the inpatient group had significantly more depressive disorder, a greater number of diagnoses, more severe symptoms, were more likely to reside in single-parent homes, and were more likely to have been physically abused.

This study reviewed 158 consecutive admissions to an inpatient adolescent psychiatric service for factors that determine length of hospitalization. Variables associated with length of stay included diagnostic category and the treatment variables of number and type of psychotropic medications prescribed. Patients with disruptive behavior disorders had the shortest hospitalizations, those with anxiety and affective disorders had stays of intermediate length, and patients with psychotic/organic disorders had the longest hospitalizations. Treatment with lithium, neuroleptics, or tricyclic antidepressants was associated with longer stays. Demographic variables and variables describing the social and family situation or level of dangerousness were not significantly associated with length of hospitalization.

The 1980s were a decade of advancement in the knowledge of anxiety disorders in children and adolescents; this sets the stage for research achievements in the 1990s. This review examines the anxiety disorders of childhood and adolescence (separation anxiety disorder, overanxious disorder, and avoidant disorder), including prevalence rates, demographic profiles, comparisons of clinical presentations in different developmental age groups, and comorbidity patterns. Fears and simple phobias, obsessive-compulsive disorder, post-traumatic stress disorder, and panic disorder in children and adolescents are also evaluated. The controversy of whether panic attacks occur in prepubertal children is addressed. A brief review of behavioral and pharmacological treatment studies is included. Future directions for research are suggested.

Two studies compared alprazolam and imipramine in the treatment of school refusal. In an open label study (N = 17), two-thirds of the subjects completing a trial in both the alprazolam and imipramine groups showed moderate to marked global improvement in symptoms of anxiety and depression. In the double-blind, placebo-controlled study (N = 24), posttreatment scores calculated as change from baseline on the Anxiety Rating for Children were significantly different (p = .03) among the three treatment groups, with the active medication groups showing the most improvement. Additionally, on all depression rating scales, similar trends were evident with the alprazolam and imipramine groups demonstrating greater improvement than the placebo group. However, analyses of covariance (with pretreatment scores as the covariates) showed no significant differences among the three treatment groups on change in anxiety and depression scales. Thus, additional research is needed to determine whether trends in this study are explained by drug effect or baseline differences on rating scales.

Two cases of electroconvulsive therapy (ECT) in adolescence are presented and the literature on the use of ECT in childhood and adolescence is reviewed. ECT was effective in children and adolescents with bipolar disorder and depression. Inadequate information exists to make a judgment regarding schizophrenia, delirium, and anorexia nervosa. ECT is not effective in autism and chronic organic brain syndromes. Complications cited include organicity and seizures in the period immediately after ECT, anxiety reactions, and disinhibition. Long-term memory deficit or cognitive impairment has not been found, although further research to rule out residual impairment is needed.

Two cases are presented in which a long-standing depressive disorder remitted after a protracted delirium associated with the exacerbation of a major medical illness. Although improvement in medical conditions may have contributed to the result, the courses of the affective and medical conditions varied independently before and after the episode of delirium. The prospect of a restitutive function for delirium is further supported by a review of six cases of tricyclic-induced delirium in patients with medical depressive syndromes: the three patients who achieved full resolution of the delirium showed affective improvement.