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The goal of the current study is to assess whether the scores of Brief Rating of Aggression by Children and Adolescents (BRACHA) at the emergency room (ER) can predict the aggressive incidents at pediatric psychiatric inpatient units. The study aims to identify predictors for two outcome measurements: 1) hazard rates for the first aggressive incident and 2) numbers of days between admission and the first aggressive incident, using the Cox regression model and Poisson regression model, respectively. The clinical records of a total of 5,610 adolescents admitted into the pediatric psychiatric inpatient units of Cincinnati Children's Hospital Medical Center were extracted for the analysis. The aggressive incident was defined as a score0 from any category of the Overt Aggression Scale (OAS) and the high-aggressive incident was defined as a score ≥ 2 from any category of the OAS. The results indicate that the BRACHA score was not associated with high-aggressive incidents (hazard ratio: 0.98, p = 0.7543). Similarly, the BRACHA scores was only associated with the number of days from admission to the first aggressive incident (Poisson regression coefficient: 0.24, p 0.0001) but not the number of days from admission to the first high-aggressive incident (Poisson regression coefficient: 0.03, p = 0.3994). Furthermore, the second peak of first aggressive incidents during the hospitalization highlights the importance of interventions at the end of the inpatient treatment course. To summarize, BRACHA scores based on initial assessments at the ER could correlate with first aggressive incidents, but not the first high-aggressive incidents.

Timely use of pharmacological interventions to treat acute agitation has the potential to decrease physical restraint use. The aim of this study is to determine if adherence to standardized pharmacological recommendations for the treatment of acutely agitated pediatric patients decreases physical restraint use. Additionally, this study aims to identify predictors of physical restraint use and describe treatment related adverse events. This is a retrospective chart review of patient visits between September 1, 2016 and August 31, 2017. Patient visits were included if the patient presented to the pediatric emergency department, met ICD-10 codes, and received pharmacologic management or physical restraint to treat acute agitation. The differences in rate of physical restraint was assessed between patients treated according to the standardized pharmacological recommendations and patients who were not. 447 patients were included with a mean age of 13 years. No significant difference in physical restraint use was found when standardized pharmacological recommendations were followed compared to when they were not (P = 0.16). Only presentation on day shift when compared to evening shift resulted in increased odds of being restrained (OR 2.03; 95% CI 1.18, 3.50). Nine adverse events possibly related to medications were identified with none considered to be of significant clinical concern. Standardized pharmacological treatment recommendations was not associated with a decrease in physical restraint use for agitated patients presenting to the pediatric emergency department. The pharmacologic strategies utilized were generally safe and well tolerated in this patient population.

Research does not occur in a vacuum. Effective stakeholder engagement occurs on several levels, including outside influence and cooperation inside the institution. Little guidance around designing and implementing pragmatic mental health research exists. The following paper outlines lessons learned during the initial stages of research design and implementation for a project focused on mental health treatment outcomes.

Children of individuals with bipolar disorder (bipolar offspring) are at increased risk for developing mood disorders, but strategies to predict mood episodes are unavailable. In this study, we used support vector machine (SVM) to characterize the potential of proton magnetic resonance spectroscopy (1H-MRS) in predicting the first mood episode in youth bipolar offspring. From a longitudinal neuroimaging study, 19 at-risk youth who developed their first mood episode (converters), and 19 without mood episodes during follow-up (non-converters) were selected and matched for age, sex and follow-up time. Baseline 1H-MRS data were obtained from anterior cingulate cortex (ACC) and bilateral ventrolateral prefrontal cortex (VLPFC). Glutamate (Glu), myo-inositol (mI), choline (Cho), N-acetyl aspartate (NAA), and phosphocreatine plus creatine (PCr + Cr) levels were calculated. SVM with a linear kernel was adopted to classify converters and non-converters based on their baseline metabolites. SVM allowed the significant classification of converters and non-converters across all regions for Cho (accuracy = 76.0%), but not for other metabolites. Considering all metabolites within each region, SVM allowed the significant classification of converters and non-converters for left VLPFC (accuracy = 76.5%), but not for right VLPFC or ACC. The combined mI, PCr + Cr, and Cho from left VLPFC achieved the highest accuracy differentiating converters from non-converters (79.0%). Our findings from this exploratory study suggested that 1H-MRS levels of mI, Cho, and PCr + Cr from left VLPFC might be useful to predict the development of first mood episode in youth bipolar offspring using machine learning. Future studies that prospectively examine and validate these metabolites as predictors of mood episodes in high-risk individuals are necessary.

INTRODUCTION: School violence has a far-reaching effect, impacting the entire school population including staff, students and their families. Among youth attending the most violent schools, studies have reported higher dropout rates, poor school attendance, and poor scholastic achievement. It was noted that the largest crime-prevention results occurred when youth at elevated risk were given an individualized prevention program. However, much work is needed to establish an effective approach to identify at-risk subjects. OBJECTIVE: In our earlier research, we developed a risk assessment program to interview subjects, identify risk and protective factors, and evaluate risk for school violence. This study focused on developing natural language processing (NLP) and machine learning technologies to automate the risk assessment process. MATERIAL AND METHODS: We prospectively recruited 131 students with or without behavioral concerns from 89 schools between 05/01/2015 and 04/30/2018. The subjects were interviewed with two risk assessment scales and a questionnaire, and their risk of violence were determined by pediatric psychiatrists based on clinical judgment. Using NLP technologies, different types of linguistic features were extracted from the interview content. Machine learning classifiers were then applied to predict risk of school violence for individual subjects. A two-stage feature selection was implemented to identify violence-related predictors. The performance was validated on the psychiatrist-generated reference standard of risk levels, where positive predictive value (PPV), sensitivity (SEN), negative predictive value (NPV), specificity (SPEC) and area under the ROC curve (AUC) were assessed. RESULTS: Compared to subjects’ sociodemographic information, use of linguistic features significantly improved classifiers’ predictive performance (P

School violence has increased over the past ten years. This study evaluated students using a more standard and sensitive method to help identify students who are at high risk for school violence. 103 participants were recruited through Cincinnati Children’s Hospital Medical Center (CCHMC) from psychiatry outpatient clinics, the inpatient units, and the emergency department. Participants (ages 12–18) were active students in 74 traditional schools (i.e. non-online education). Collateral information was gathered from guardians before participants were evaluated. School risk evaluations were performed with each participant, and audio recordings from the evaluations were later transcribed and manually annotated. The BRACHA (School Version) and the School Safety Scale (SSS), both 14-item scales, were used. A template of open-ended questions was also used. This analysis included 103 participants who were recruited from 74 different schools. Of the 103 students evaluated, 55 were found to be moderate to high risk and 48 were found to be low risk based on the paper risk assessments including the BRACHA and SSS. Both the BRACHA and the SSS were highly correlated with risk of violence to others (Pearson correlations>0.82). There were significant differences in BRACHA and SSS total scores between low risk and high risk to others groups (p-values

School violence has increased over the past decade and innovative, sensitive, and standardized approaches to assess school violence risk are needed. In our current feasibility study, we initialized a standardized, sensitive, and rapid school violence risk approach with manual annotation. Manual annotation is the process of analyzing a student's transcribed interview to extract relevant information (e.g., key words) to school violence risk levels that are associated with students' behaviors, attitudes, feelings, use of technology (social media and video games), and other activities. In this feasibility study, we first implemented school violence risk assessments to evaluate risk levels by interviewing the student and parent separately at the school or the hospital to complete our novel school safety scales. We completed 25 risk assessments, resulting in 25 transcribed interviews of 12-18 year olds from 15 schools in Ohio and Kentucky. We then analyzed structured professional judgments, language, and patterns associated with school violence risk levels by using manual annotation and statistical methodology. To analyze the student interviews, we initiated the development of an annotation guideline to extract key information that is associated with students' behaviors, attitudes, feelings, use of technology and other activities. Statistical analysis was applied to associate the significant categories with students' risk levels to identify key factors which will help with developing action steps to reduce risk. In a future study, we plan to recruit more subjects in order to fully develop the manual annotation which will result in a more standardized and sensitive approach to school violence assessments.

The current adult and child forensic psychiatrist is well trained, familiar, and comfortable with the use of the semi-structured Diagnostic and Statistical Manual of Mental Disorders, 5th Edition, APA 2013 (DSM-5) [In APA, 2003] interview style. The author's assertion is not that this method is invalid or unreliable; rather, that it can be complemented by integrating elements of the defendant's four pillar assessment. Assessing the four pillars expands on the information provided by a semi-structured DSM-5-style interview in psychiatry. The four pillars are the foundation of a person's personality; temperament, cognition (learning abilities or weaknesses), cognitive flexibility (theory of mind) and internal working models of attachment, within the backdrop of the family and of the social and cultural environment in which they have lived. The importance of the study of four pillars is based on the understanding that human behavior and psychopathology as a complex and multifaceted process that includes the level of social-emotional maturity and cognitive abilities (In Delgado et al. Contemporary Psychodynamic Psychotherapy for Children and Adolescents: Integrating Intersubjectivity and Neuroscience. Springer, Berlin, 2015). The four pillars are not new concepts, rather they had been studied by separate non-clinical disciplines, and had not been integrated to the clinical practice. As far as we know, it wasn't until Delgado et al. (Contemporary Psychodynamic Psychotherapy for Children and Adolescents: Integrating Intersubjectivity and Neuroscience. Springer, Berlin, 2015) incorporated the four pillars in a user-friendly manner to clinical practice.

Social information processing theory hypothesizes that aggressive children pay more attention to cues of hostility and threat in others’ behavior, consequently leading to over-interpretation of others’ behavior as hostile. While there is abundant evidence of aggressive children demonstrating hostile attribution biases, less well documented is whether such biases stem from over-attendance and hypersensitivity to hostile cues in social situations. Over-attendance to hostile cues would be typified by deviations at any stage of the multi-stage process of social information processing models. While deviations at later stages in social information processing models are associated with aggressive behavior in children, the initial step of encoding has historically been difficult to empirically measure, being a low level automatic process unsuitable for self-report. We employed eye-tracking methodologies to better understand the visual encoding of such social information. Eye movements of ten 13–18 year-old children referred from clinical and non-clinical populations were recorded in real time while the children viewed scenarios varying between hostile, non-hostile and ambiguous social provocation. In addition, the children completed a brief measure of risk of aggression. Aggressive children did attend more to the social scenarios with hostile cues, in particular attending longest to those hostile scenarios where the actor in the scenario had a congruent emotional response. These findings corroborate social information processing theory and the traditional bottom-up processing hypotheses that aggressive behavior relates to increased attention to hostile cues.

Here we report a case of a 15-year-old female who had originally been diagnosed and treated unsuccessfully for schizophrenia, psychosis, severe anxiety, and depression. More in-depth history revealed an abrupt onset of her symptoms with remote acute infections and many exhibited characteristics of obsessive compulsive disorder with rituals. Work-up for underlying infectious, immunodeficiency, and autoimmune causes was unrevealing except for very high levels of anti-neuronal antibodies which have been linked to Pediatric Acute-onset Neuropsychiatric Syndrome (PANS). Treatment options were discussed with the family and it was decided to use a course of plasmapheresis based on previous studies demonstrating efficacy and its safety profile. After course of therapy, there was a dramatic resolution of her psychosis, OCD traits, and anxiety. She was able to stop all of her antipsychotic and anxiety medications and resume many of her previous normal daily activities. The effect of this treatment has been sustained to the present time. This case emphasizes the importance of exploring nontraditional treatments for severe, treatment-resistant mental illness which requires a multidisciplinary approach. Further research is warranted in larger populations to investigate pathomechanisms and treatment of PANs/PANDAs.

The mechanisms underlying aggression in adolescents with bipolar disorder have been poorly understood. The present study has investigated the associations among TNF gene expressions, functional brain activations under the frustrative non-reward task, and aggression in adolescents with bipolar disorder. Baseline gene expressions and aggressive tendencies were measured with the RNA-sequencing and Brief Rating of Aggression by Children and Adolescents (BRACHA), respectively. Our results show that activity levels of left subgenual anterior cingulate gyrus (ACG) right amygdala, left Brodmann area 10 (orbitofrontal cortex), and right thalamus were inversely correlated with BRACHA scores and were activated with frustrative non-reward during the affective Posner Task. In addition, eleven TNF related gene expressions were significantly correlated with activation of amygdala or ACG during the affective Posner task. Three TNF gene expressions were inversely correlated with BRACHA score while one TNF gene (TNFAIP3) expression was positively correlated with BRACHA score. Therefore, TNF-related inflammatory cytokine genes may play a role in neural activity associated with frustrative non-reward and aggressive behaviors in pediatric bipolar disorder.

In pediatric patients with anxiety disorders, existing symptom inventories are either not freely available or require extensive time and effort to administer. We sought to evaluate a brief self-report scale-the Generalized Anxiety Disorder 7-item scale (GAD-7)-in adolescents with generalized anxiety disorder (GAD).The Pediatric Anxiety Rating Scale (PARS) and the GAD-7 were administered to youth with GAD (confirmed by structured interview). Relationships between the measures were assessed, and sensitivity and specificity was determined with regard to a global symptom severity measure (Clinical Global Impression-Severity).In adolescents with GAD (N = 40; mean age, 14.8 ± 2.8), PARS and GAD-7 scores strongly correlated (R = 0.65, P ≤ .001) and a main effect for symptom severity was observed (P ≤ .001). GAD-7 scores ≥11 and ≥17 represented the optimum specificity and sensitivity for detecting moderate and severe anxiety, respectively.The PARS and GAD-7 similarly reflect symptom severity. The GAD-7 is associated with acceptable specificity and sensitivity for detecting clinically significant anxiety symptoms. GAD-7 scores may be used to assess anxiety symptoms and to differentiate between mild and moderate GAD in adolescents, and may be more efficient than the PARS.

Conduct disorder (CD), a psychiatric condition that is prevalent in some child and adolescent populations, is defined by the DSM-5 as a repetitive and persistent pattern of behavior in which the rights of others and age-appropriate cultural norms are violated. DSM-5 subtypes include childhood-onset, adolescent-onset, and callous-unemotional presentations. The development of CD is affected by gender, age at onset, environmental factors, and genetic factors. Overall, it has been difficult to identify causative factors because there is such a diverse variety of factors and comorbidities involved, although studies to define specific genetic, physiologic, and neurologic links to CD are ongoing. Common comorbidities in CD include oppositional defiant disorder, attention-deficit/hyperactivity disorder (ADHD), major depressive disorder, bipolar disorder, dysthymia, and substance abuse. The most successful treatment involves a multisystemic approach involving medication, family therapy, educational therapy, and parenting skills. Overall, early prevention of CD through treatment is key because the prognosis is poor and can be associated with the development of more severe comorbidities. This review contains 3 tables, and 58 references. Key words: antisocial behavior behavioral issues, ADHD comorbidities, child mental disorders, conduct disorder

Attention deficit hyperactive disorder (ADHD) is one of the most commonly diagnosed childhood mental disorders. This pervasive disorder can affect all aspects of the child's life, including, but not limited to: peer relations, adult relations and intellectual development. As a direct result of ADHD, many of these deficiencies pervade through the child's life into adulthood. Although there is a growing number of literature focusing on the sequela of ADHD, especially social deviance, most of the literature's scope is limited to the connection between ADHD and criminality. This finite perspective provides little insight into the developmental characteristics which actually link ADHD to criminality. The most glaring example of an obscured developmental link is that of moral judgment. The following is an attempt to draw a meaningful connection between deficient moral development and ADHD, especially as it relates to attachment theory. Connecting previous research relevant to the topic as well as time-tested psychological theories on morality and attachment will serve to validate this claim.

Aggression is a common management problem for child psychiatry hospital units. We describe an exploratory study with the primary objective of establishing the feasibility of linking salivary concentrations of three hormones (testosterone, dehydroepiandrosterone [DHEA], and cortisol) with aggression. Between May 2011 and November 2011, we recruited 17 psychiatrically hospitalized boys (age 7–9 years). We administered the Brief Rating of Aggression by Children and Adolescents (BRACHA) and Predatory-Affective Aggression Scale (PAAS) upon admission. Saliva samples were collected from the participants during a 24-h period shortly after admission: immediately upon awakening, 30 min later, and again between 3:45 and 7:45 P.M. Nursing staff recorded Overt Aggression Scale ratings twice a day during hospitalization to quantify aggressive behavior. The salivary cortisol concentrations obtained from aggressive boys 30 min after awakening trended higher than levels from the non-aggressive boys (p = 0.06), were correlated with the number of aggressive incidents (p = 0.04), and trended toward correlation with BRACHA scores (p = 0.06). The aggressive boys also showed greater morning-to-evening declines in cortisol levels (p = 0.05). Awakening levels of DHEA and testosterone were correlated with the severity of the nearest aggressive incident (p < 0.05 for both). The BRACHA scores of the aggressive boys were significantly higher than scores of the non-aggressive boys (p < 0.001). Our data demonstrate the feasibility of collecting saliva from children on an inpatient psychiatric unit, affirm the utility of the BRACHA in predicting aggressive behavior, and suggest links between salivary hormones and aggression by children who undergo psychiatric hospitalization.

Attention deficit hyperactivity disorder (ADHD) is often associated with symptoms of aggression in children and adolescents. Clinically, this is complex because aggression can be from hyperactivity and impulsivity, or could be a distinct symptom from a comorbid diagnosis. Past research has recommended first treating the primary disorder of ADHD. Stimulants are the most common treatment for pediatric ADHD, which can be helpful in decreasing aggressive behaviors. Alpha-adrenergic agonists and atomoxetine (ATX) are non-stimulant medications for ADHD and aggression, but more research is necessary to compare these drugs to stimulants. If aggressive symptoms do not improve from treating the primary disorder, aggression can be treated separately. Risperidone, lithium, valproic acid, clonidine, and guanfacine have shown positive results in reducing aggression, but studies including children with aggression and ADHD are limited. The variability in treatment tolerability in patients has stimulated research in pharmacogenetics for ADHD. Although this field is still emerging, research has found evidence supporting a link between the response rate of methylphenidate and the dopamine transporter (DAT1) and a link between the metabolism rate of atomoxetine and hepatic cytochrome 450 isozymes. Pharmacogenetics may be relevant to ADHD and associated aggression. Further research in pharmacogenetics will strive to identify patterns of genetic variations that can tailor individual treatments.

Objective To examine prefrontal and amygdala activation during emotional processing in youth with or at varying risk for developing mania to identify candidate central prodromal risk biomarkers. Method Four groups of medication-free adolescents (10–20 years old) participated: adolescents with first-episode bipolar I disorder (BP-I; n = 32), adolescents with a parent with bipolar disorder and a depressive disorder (at-risk depressed [ARD]; n = 32), healthy adolescents with a parent with bipolar disorder (at-risk healthy [ARH]; n = 32), and healthy adolescents with no personal or family history of psychiatric illness (healthy comparison [HC]; n = 32). Participants underwent functional magnetic resonance imaging while performing a continuous performance task with emotional and neutral distracters. Region-of-interest analyses were performed for the bilateral amygdala and for subregions of the ventrolateral prefrontal cortex and anterior cingulate cortex. Results Overall, no group differences in bilateral amygdala and ventrolateral prefrontal cortex (Brodmann area [BA] 45/47) activation during emotional or neutral stimuli were observed. The BP-I group exhibited lower right pregenual anterior cingulate cortex activation compared with the HC group, and activation in the left BA 44 was greater in the ARH and ARD groups compared with the HC group. BP-I and ARD groups exhibited blunted activation in the right BA 10 compared with the ARH group. Conclusion During emotional processing, amygdala and ventrolateral prefrontal cortex (BA 45/47) activation does not differ in youth with or at increasing risk for BP-I. However, blunted pregenual anterior cingulate cortex activation in first-episode mania could represent an illness biomarker, and greater prefrontal BA 10 and BA 44 activations in at-risk youth could represent a biomarker of risk or resilience warranting additional investigation in prospective longitudinal studies.

This retrospective study compared frequencies of aggressive behaviors and abuse histories noted during a psychiatric intake assessment for children where animal cruelty was endorsed and a control sample of youth for whom animal cruelty was not endorsed to determine if rates of concerning behaviors differed significantly. Relative to the control group, the cruelty group was significantly more likely to have had problems with peers, perpetrated bullying, experienced sexual abuse, and have a history of sexually acting out. Recommendations for childhood animal cruelty screening in mental health settings are discussed.

Acute agitation is a state of behavioral dyscontrol that requires intervention. Medications available in rapid delivery formats are frequently administered to treat acute agitation, either as a chemical restraint or on a voluntary basis. Prior to initiating treatment, the etiology of agitation must be evaluated. In choosing a medication, general pharmacologic principles should be followed. Medication should be selected based on the underlying cause in conjunction with weighing the risks, benefits, and side effects of medications. There are three classes of medications administered to children and adolescents to treat agitation: antihistamines, benzodiazepines, and antipsychotics. The most concerning short-term side effects of antipsychotics are their adverse neurologic effects, neuroleptic malignant syndrome, and prolonged corrected QT interval. Compared with typical antipsychotics, atypical antipsychotics have a more favorable short-term side effect profile.

An evidence-based practice project was completed to develop best practice recommendations for the treatment of aggression in children and adolescents with attention deficit hyperactivity disorder (ADHD). Ovid Medline, PsychInfo, the National Guidelines Clearinghouse, and the Cochrane Database of Systematic Reviews were searched with limits set for English language, years 1996 to January 2010. A search of the pediatric literature was conducted for synthesized evidence in the form of meta-analyses, systematic reviews, or practice guidelines related to the treatment of aggression in children and adolescents with attention deficit hyperactivity disorder. Data were extracted using the LEGEND system. Three evidence-based care recommendations for the management of aggression in children and adolescents with ADHD were developed with an associated grade for the body of evidence. First-line pharmacotherapy for aggressive behavior in children and adolescents with ADHD should be ADHD medications. Additional research is needed to evaluate the efficacy of psychiatric medications on signs of aggression within the context of ADHD.

Our primary objective was to evaluate the effectiveness and tolerability of intramuscular ziprasidone for impulsivity and agitation in psychiatrically hospitalized children and adolescents. Our secondary objective was to examine demographic and clinical factors associated with treatment response.We conducted a retrospective chart review of children and adolescents admitted to Cincinnati Children's Hospital Medical Center (CCHMC) psychiatric units between January 1, 2002, and July 11, 2005, who received intramuscular ziprasidone. Medical records were reviewed to determine demographic and clinical information as well as tolerability and effectiveness of ziprasidone. The Behavioral Activity Rating Scale (BARS) was used retrospectively to assess clinical response. Regression analyses were performed to evaluate the effect of demographic factors (age, gender, and ethnicity) and primary psychiatric diagnoses on treatment response. Electrocardiogram (ECG) data was inadequate.Fifty nine children and adolescents received a total of 77 injections of intramuscular ziprasidone for acute agitation. The mean +/- SD BARS score decreased from 6.5 +/- 0.7 to 3.1 +/- 1.3. The most common side effect was drowsiness or falling asleep (n = 46, 60%). Three (4%) could not be roused after the injection.Intramuscular ziprasidone may be helpful for agitation but often caused oversedation. Safety data, including ECGs, is needed in controlled prospective studies.

The purpose of this study was to examine body mass indexes (BMI) and lipid profiles of children and adolescents hospitalized for a psychiatric illness and exposed to an atypical antipsychotic.Medical records of children and adolescents (ages of 5-18 years) with an inpatient psychiatric hospitalization between July 1, 2004, and June 30, 2005, were reviewed. Subjects were required to have been treated with at least one atypical antipsychotic during the month prior to admission. Height, weight, and fasting lipid values completed upon admission were collected. Prevalences of overweight (sex-specific BMI for ageor=the 95th percentile) and at risk for overweight (sex-specific BMI for age between the 85th and 94.9th percentiles) were determined and compared to estimates from the 2001-2002 National Health and Nutrition Examination Survey (NHANES) data. The prevalence of abnormal lipid profiles was also evaluated using widely accepted criteria specific for pediatric patients. Exploratory multiple linear regression models were fit to examine relationships of demographic and clinical variables with BMI z-scores and lipid profiles.Of 95 inpatients (mean age 14 years, 43% female, and 60% white) evaluated, 16% (n=15) were at risk for overweight and 53% (n=50) were overweight. Fifty-one percent (n=48) and 48% (n=46) of the sample had elevated triglycerides (TG) levels and low high-density lipoprotein (HDL) levels, respectively.The prevalence of overweight among hospitalized children and adolescents with exposure to atypical antipsychotics is triple that of national norms. Dyslipidemia was also common in this inpatient sample. Future studies should assess the development of overweight, the factors contributing to it, and related comorbidities in youths with mental illness.

Barzman DH, DelBello MP, Fleck DE, Lehmkuhl H, Strakowski SM. Rates, types, and psychosocial correlates of legal charges in adolescents with newly diagnosed bipolar disorder. Bipolar Disord 2007: 9: 339-344. © Blackwell Munksgaard, 2007 Objectives: To examine the rates, types, and psychosocial correlates of legal charges in adolescents with newly diagnosed bipolar disorder (BD). Methods: Adolescents (n = 80), between the ages of 12 and 21 years (mean = 15.6, standard deviation - 2.3), hospitalized for their initial manic or mixed episode of BD, were evaluated for the incidence of prior juvenile offending (i.e., legal charges). We examined potential psychosocial correlates associated with legal charges using chi-square, (t-tests, and discriminant function analyses to determine if there were differences between adolescents who did and did not offend prior to their first manic episode. Results: Juvenile antisocial behaviors were common (55%) for adolescents with newly diagnosed BD. Discriminant function analysis revealed that older age at first treatment (p < 0.01), sexual activity over the previous month (p < 0.05), therapeutic use of stimulants (p < 0.05), and anxiety disorders were the most significant factors to differentiate between bipolar adolescents who offended and those who did not (Wilks' lambda = 0.80, p < 0.005). Conclusions: Our findings indicate that there are identifiable psychosocial correlates associated with antisocial behaviors in adolescents with newly diagnosed BD that may improve our understanding of juvenile antisocial behaviors.

Patients with chronic depression may suffer from global cognitive defects. Here, we present a case with repetitive mild traumatic brain injuries (mTBI) that aggravated her depressive symptoms and exhibited atypical cognitive impairments. Her depressive symptoms had been resistant to a combination of SNRI and antipsychotics. The single-photon emission computed tomography scan showed asymmetric perfusion at medial temporal lobes - which has been found to be associated with somatic delusions in some other patients. Her cognitive impairment profile was also consistent with difficulty in inhibition and visual processing, as noted in medial temporal lobe dysfunction, but not commonly seen in chronic depression. After her depression was improved with antipsychotic medications, her specific cognitive impairments persisted. To conclude, repetitive mTBI might cause selective or atypical cognitive impairments that impact treatment responses in patients with depressive disorders.

The aim of this study was to compare the efficacy and tolerability of quetiapine and divalproex for the treatment of impulsivity and reactive aggression in adolescents with co-occurring bipolar disorder and disruptive behavior disorders.Patients were included in this post hoc analysis if they scoredor = 14 on the Positive and Negative Syndrome Scale (PANSS) Excited Component (EC) andor = 4 on at least one of the PANSS EC items, had a current diagnosis of bipolar I disorder, manic or mixed episode, and had a lifetime and/or current diagnosis of a disruptive behavioral disorder (DBD) [conduct disorder (CD) or oppositional defiant disorder (ODD)]. Thirty-three (92%) of the 36 subjects with bipolar disorder and DBD met the PANSS EC inclusion criteria. These thirty-three adolescents were randomized to quetiapine (400-600 mg/day) or divalproex (serum level 80-120 microg/mL) for 28 days in this double-blinded study. The primary efficacy measure was change in PANSS Excited Component (EC) score over the study period and at each time point.Repeated measures analysis of variance (ANOVA) demonstrated statistically significant within-treatment-group effects for divalproex (baseline = 20.6, end point = 13.3, p0.0001) and quetiapine (baseline = 18.8, end point = 10.8, p0.0001) for the PANSS EC. There were no statistically significant treatment group differences in PANSS EC changes from baseline to end point scores (p = 0.7, d = 0.14). Mixed regression analyses (comparison of slopes, DAY*TREATMENT) revealed that there was no significant difference in the rate of improvement in the PANSS EC scores between the two treatment groups [F(1,31) = 0.78, p = 0.39, d = 0.28].Quetiapine and divalproex showed similar efficacy for the treatment of impulsivity and reactive aggression related to co-occurring bipolar and disruptive behavior disorders in adolescents. Quetiapine and divalproex are both useful as monotherapy for the treatment of impulsivity and reactive aggression in adolescents with bipolar and disruptive behavior disorders. Placebo-controlled studies are necessary.

Background The objective of this retrospective chart review was to evaluate the phenomenology and response to divalproex in a sub-population of children admitted to an inpatient setting with severe impairing symptoms of irritability and aggression. In addition, we examined whether the symptomatology of this group was consistent with a pediatric divalproex-responsive bipolar spectrum disorder. Methods The charts of 46 child and adolescent patients with prominent impulsive aggression with irritability admitted to a crisis stabilization center were assessed retrospectively. Impulsive aggressive symptoms were assessed for admission and discharge severity by two clinicians using the Overt Aggression Scale (OAS) and the Anger-Hostility Subscale of the SCL-90 (SCL-A), with overall functioning changes assessed using the Children's Global Assessment Scale (C-GAS). Results Statistically significant improvements were obtained for the group in the C-GAS, with significant decreases in the OAS and the SCL-A scores at discharge, following a maximal 14-day stay. No severe side effects were reported. All patients met the criteria for a potential pediatric bipolar phenotype. Limitations This was a retrospective study without randomization or a control group. Additionally, the non-blinded design may have biased the raters concerning the effectiveness of divalproex for impulsive aggression. Conclusions Our data are in line with divalproex response in children and adolescents with target symptoms of explosive temper and mood instability. Our data further suggest that such symptoms, coupled with impulsive aggression and irritability, as well as related manic symptoms, constitute a pediatric divalproex-responsive bipolar spectrum disorder.

The aim of this retrospective chart review was to evaluate the effectiveness and tolerability of aripiprazole for the treatment of children and adolescents with bipolar disorders.The medical charts of all children and adolescents with a DSM-IV diagnosis of bipolar disorder, type I, type II, not otherwise specified (NOS), or schizoaffective disorder, bipolar type, and who were treated with aripiprazole were reviewed by two child and adolescent psychiatrists who independently confirmed their DSM-IV diagnoses, severity, and the improvement of illness using the Clinical Global Impression (CGI) Severity and Improvement scores for bipolar disorder (CGI-BP) and the Clinical Global Assessment Scale (CGAS).Thirty patients who were treated with aripiprazole were identified (mean starting dose=9 +/- 4 mg/day, mean final dose=10 +/- 3 mg/day). The overall response rate, defined by a CGI-Improvement score ofor = 2 at endpoint, was 67%. There was a statistically significant improvement in CGAS scores (48 +/- 11 to 65 +/- 11, signed rank = 191, p0.0001) and CGI-S scores (4.2 +/- 0.8 to 2.8 +/- 1.0, signed rank=-172, p0.0001, effect size=1.90) from baseline to endpoint. No serious adverse events were identified. Common side effects were sedation (n=10, 33%), akathisia (n=7, 23%), and gastrointestinal disturbances (n=2, 7%). Baseline and endpoint weights were available for 14 (47%) of the patients. Change in weight ranged from +5 to -21 kg and 12 (86%) of 14 patients lost weight (mean weight loss was 3 +/- 6 kg).This retrospective chart review suggests that aripiprazole may be effective and well tolerated for children and adolescents with bipolar disorders. Controlled studies of aripiprazole for the treatment of pediatric bipolar disorder are necessary.

Atypical antipsychotics, which include clozapine (Clozaril), risperidone (Risperdal), olanzapine (Zyprexa), quetiapine (Seroquel), aripiprazole (Abilify), and ziprasidone (Geodon) are approved by the U.S. Food and Drug Administration (FDA) for adults with bipolar disorder and schizophrenia. However, currently, no atypical antipsychotic has been approved by the FDA for use in children and adolescents. Nonetheless, clinicians frequently prescribe these medications for children and adolescents since they have lower rates of side effects than conventional antipsychotics. Although these medications can treat a broad range of psychiatric disorders in childhood, we will focus on the treatment of pediatric psychotic disorders such schizophrenia, schizoaffective disorder, psychotic mood disorders, psychosis due to a medical condition, and psychosis not otherwise specified (NOS). Children and adolescents are often initially diagnosed with psychosis NOS since there may be evidence of psychotic symptoms but they do not meet the threshold for another DSM–IV psychotic disorder. Additionally, in new onset psychosis, it can be difficult to uncover the primary illness since developmental issues, such as multiple co–occurring diagnoses and age–specific manifestations of psychotic disorders complicate diagnosis. Indeed, studies have shown that there is frequently a three year delay prior to treatment for the first episode of psychosis in children and adolescents. However, early treatment may be important in preventing neurotoxicity. Therefore, clinicians need to feel comfortable with using atypical antipsychotics for psychotic disorders in pediatric patients. The goal of this review is to discuss possible side effects, the management and monitoring of adverse effects, and typical dosing of atypical antipsychotics in the treatment of psychotic disorders in children and adolescents. Although there has been evidence for the efficacy and effectiveness of atypical antipsychotics in children and adolescents, there have been few controlled studies. In a 6–week double–blind comparison of clozapine and haloperidol for childhood–onset schizophrenia (N = 21, mean age = 14), clozapine was found to be more efficacious for positive and negative symptoms. Risperidone has also been found to be efficacious for pediatric psychosis in case reports, retrospective reviews, and open–label prospective studies (age: 6–18, dose: 0.5 mg–10 mg/day). Seven open–label studies (N > 100) have suggested that olanzapine may be efficacious for pediatric psychosis (age: 6–18, dose: 2.5 mg–20 mg/day). In a double–blind parallel study of risperidone, olanzapine, and haloperidol (Sikich et al, 2004) for psychosis in adolescents (N = 50, age range = 8–19, mean age = 15), risperidone (0.5 mg–3 mg, max = 6 mg) and olanzapine (2.5 mg–12.5 mg, max = 20 mg) had superior efficacy as compared to haloperidol (1 mg–5 mg, max = 8 mg). There have been case reports and two open label studies that have suggested that quetiapine may be efficacious for the treatment of psychosis in adolescents (dose = 400 mg BID, age range = 12–16). To our knowledge, there has been no published data on the use of aripiprazole or ziprasidone for psychosis in children and adolescents. Adverse Effects of Second Generation Antipsychotics (SGAs)

Previous evidence suggests that emotion dysregulation may have different biological correlates between adults and children/adolescents. Although the role of genetic factors has been extensively studied in adult-onset emotion dysregulation, the genetic basis for pediatric-onset emotion dysregulation remains elusive. The current review article presents a summary of previous studies that have suggested a few genetic variants associated with pediatric emotion dysregulation. Among these candidate loci, many prior studies have been focused on serotonin transporter promoter gene polymorphism 5-HTTLPR. Certain alleles of the 5-HTTLPR gene polymorphism have been found to be associated with traits associated with emotion dysregulation, such as aggression, affect reactivity, and insecure attachment. Additionally, genetic variants involving dopamine and neurophysiological biomarkers like the COMT Val158Met (rs460) and dopamine receptor D2/ ankyrin repeat and kinase domain containing one polymorphisms may play a role in emotion dysregulation. Inconsistent findings have been noted, possibly due to the heterogeneity in study designs and characteristics of different populations. Further research on the role of genetic predetermination of emotion dysregulation in children and adolescents is warranted.

The following review article examines the value of a dimensional approach to research in relation to recent findings of child and adolescent emotion dysregulation. With the publication of the DSM-5, it is important to keep in mind that difficulties in pinpointing causal mechanisms may result from the collective grouping of different emotional deficits by diagnoses. Evidence available from studies examining pediatric emotion dysregulation indicate strengths in the dimensional approach for research, especially in light of developmental changes to neural activations of emotion regulation. Use of a dimensional approach in research appears to be an effective tactic that could pave the way for a better understanding of pediatric emotion dysregulation and thereby elucidate better treatments and outcomes for those with this behavioral deficit, regardless of diagnosis.

OBJECTIVE: Depressive and anxiety disorders are common in youth who are at risk for bipolar disorder (i.e., youth who have at least one parent with bipolar disorder) and antidepressants are commonly prescribed as treatment. However, there are few data regarding the safety and tolerability of antidepressants in this population. Therefore, we sought to prospectively examine the effects of these medications in children and adolescents who are diagnosed with depressive or anxiety disorders and have a parent with bipolar I disorder. METHODS: Youth aged 9-20 years, with at least one parent with bipolar I disorder [high risk (HR)], were recruited (n = 118) and assessed using semi-structured diagnostic interviews. Participants were prospectively evaluated using a modified version of the Longitudinal Interval Follow-up Evaluation to assess changes in affective and anxiety symptoms and were treated naturalistically. RESULTS: Over the course of 43-227 weeks (mean duration of follow-up: 106 ± 55 weeks), 21% (n = 25) of youth had antidepressant exposure and, of these, 57% (n = 12) had an adverse reaction (e.g., irritability, aggression, impulsivity, or hyperactivity) that led to antidepressant discontinuation. Those patients who experienced an adverse reaction were significantly younger than those who did not (p = 0.02) and discontinuation of antidepressant therapy secondary to an adverse event occurred at an average of 16.7 ± 17.4 weeks (median: 11 weeks, range: 2-57 weeks). Cox proportional hazard analyses yielded a hazard ratio of 0.725 (p = 0.03), suggesting that there is a 27% decrease in the likelihood of an antidepressant-related adverse event leading to discontinuation with each one-year increase in age. CONCLUSIONS: Antidepressant medications may be poorly tolerated in youth with a familial risk for developing mania. Controlled studies further assessing treatments for depression and anxiety in HR youth are urgently needed. Language: en

The present paper reviews pediatric posttraumatic stress disorder, emphasizing the relational basis of the disorder and highlighting the missing link between juvenile delinquency and trauma. The first part of the paper defines trauma and the diagnostic criteria for PTSD, noting child-specific features. The second part reviews the literature emphasizing the relational and attachment relevant nature of trauma. The third part explores psychological mechanisms for how attachment relations could affect trauma responses. Attachment relations (1) shape core schemas of the world, others, and the self and (2) foster emotional engagement or disengagement, both of which have been associated with traumatic responses. The most empirically supported pediatric trauma treatment, trauma-focused cognitive behavioral therapy (TF-CBT), acknowledges the attachment figure's influence and includes treating and training the parent and conjoint child-parent discussion. The next section reviews the noteworthy link between juvenile delinquency and trauma history. More awareness of trauma and PTSD in children and adolescents is recommended to effectively address juvenile delinquency. The review ends with a few helpful points for practicing pediatricians regarding childhood trauma.

This study evaluated the Brief Rating of Aggression by Children and Adolescents-Preliminary Version (BRACHA 0.8), an actuarial method of assessing the risk of aggressive behavior by hospitalized children and adolescents. Licensed psychiatric social workers used a 16-item questionnaire to assess all patients seen in the emergency department (ED) of a major urban children's hospital. Over a six-month period, 418 patients (age range, 3.5-19.0 years) underwent psychiatric hospitalization after ED evaluation. The hospital nursing staff recorded the inpatients' behavior, with the Overt Aggression Scale (OAS). Inpatients were deemed aggressive if, during the first six days of their hospital stay, they scored one or higher on any OAS subscale. We evaluated questionnaire properties, items, and demographic covariates (e.g., age, sex, and living situation) by using factor analyses, logistic regression models, and receiver operating characteristic (ROC) methods. A total of 292 aggressive acts were committed by 120 (29% of 418) patients. Fourteen of the 16 items predicted (p.007) inpatient aggression and showed good internal consistency (Cronbach's α = 0.837). Age was inversely related to probability of aggression and was incorporated into the final assessment instrument. Predictive power was comparable with other published risk assessment instruments (ROC areas of .75 for any aggression and .82 for aggression toward others). BRACHA 0.8 shows promise in rapidly assessing risk of inpatient aggression, but further studies are needed to establish the reliability and validity of the instrument.

The answer for treating pathologic aggression (PA) in children on inpatient psychiatry units (based on various factors like severity of aggression and co-morbidities) is less likely to be restrictive interventions or sedating the patient. Using seclusion and restraints or medications to calm down the aggression is not free of adverse consequences. A protocol is needed to safely and effectively address aggressive and violent children and adolescents seen very commonly in psychiatry inpatient units.