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Aim Social impairment is common in individuals with bipolar disorder (BD), although its role in youths at high-risk for BD (i.e., mood symptoms in the context of a family history of BD) is not well understood. Social impairment takes many forms including social withdrawal, relational aggression, physical aggression, and victimization. The aim of this study was to explore the links between social impairment and clinical symptoms in youth at high-risk for BD. Methods The sample included 127 youths with elevations in mood symptoms (depression or hypomania) and at least one first and/or second degree relative with BD. Measures of youths' current psychopathology (i.e., depressive and manic severity, suicidality, anxiety, and attention-deficit/hyperactivity disorder [ADHD]) were regressed onto youths' self-reports of social impairment (i.e., social withdrawal, relational aggression, physical aggression, and victimization). Results Depressive symptoms, suicidal ideation, and anxiety symptoms were related to social withdrawal. Suicidal ideation was also related to reactive aggression. ADHD symptoms related to reactive and proactive aggression as well as relational victimization. Manic symptoms were not associated with social impairment in this sample. Conclusions Although cross-sectional, study findings point to potential treatment targets related to social functioning. Specifically, social withdrawal should be a target for treatment of childhood depressive and anxiety symptoms. Treatments that focus on social skills and cognitive functioning deficits associated with BD may also have clinical utility.

IMPORTANCE: Behavioral high-risk phenotypes predict the onset of bipolar disorder among youths who have parents with bipolar disorder. Few studies have examined whether early intervention delays new mood episodes in high-risk youths. OBJECTIVE: To determine whether family-focused therapy (FFT) for high-risk youths is more effective than standard psychoeducation in hastening recovery and delaying emergence of mood episodes during the 1 to 4 years after an active period of mood symptoms. DESIGN, SETTINGS, AND PARTICIPANTS: This multisite randomized clinical trial included referred youths (aged 9–17 years) with major depressive disorder or unspecified (subthreshold) bipolar disorder, active mood symptoms, and at least 1 first- or second-degree relative with bipolar disorder I or II. Recruitment started from October 6, 2011, and ended on September 15, 2016. Independent evaluators interviewed participants every 4 to 6 months to measure symptoms for up to 4 years. Data analysis was performed from March 13 to November 3, 2019. INTERVENTIONS: High-risk youths and parents were randomly allocated to FFT (12 sessions in 4 months of psychoeducation, communication training, and problem-solving skills training; n = 61) or enhanced care (6 sessions in 4 months of family and individual psychoeducation; n = 66). Youths could receive medication management in either condition. MAIN OUTCOMES AND MEASURES: The coprimary outcomes, derived using weekly psychiatric status ratings, were time to recovery from prerandomization symptoms and time to a prospectively observed mood (depressive, manic, or hypomanic) episode after recovery. Secondary outcomes were time to conversion to bipolar disorder I or II and longitudinal symptom trajectories. RESULTS: All 127 participants (82 [64.6%] female; mean [SD] age, 13.2 [2.6] years) were followed up for a median of 98 weeks (range, 0–255 weeks). No differences were detected between treatments in time to recovery from pretreatment symptoms. High-risk youths in the FFT group had longer intervals from recovery to the emergence of the next mood episode (χ(2) = 5.44; P = .02; hazard ratio, 0.55; 95% CI, 0.48–0.92;), and from randomization to the next mood episode (χ(2) = 4.44; P = .03; hazard ratio, 0.59; 95% CI, 0.35–0.97) than youths in enhanced care. Specifically, FFT was associated with longer intervals to depressive episodes (log-rank χ(2) = 6.24; P = .01; hazard ratio, 0.53; 95% CI, 0.31–0.88) but did not differ from enhanced care in time to manic or hypomanic episodes, conversions to bipolar disorder, or symptom trajectories. CONCLUSIONS AND RELEVANCE: Family skills-training for youths at high risk for bipolar disorder is associated with longer times between mood episodes. Clarifying the relationship between changes in family functioning and changes in the course of high-risk syndromes merits future investigation. TRIAL REGISTRATION: ClinicalTrials.gov identifier: NCT01483391.

Objectives Pediatric psychogenic nonepileptic seizures (PNES) is a functional somatic symptom condition with significant health-care service burden. While both family and individual factors play an important role in the development and maintenance of PNES, little is known about what predicts urgent health-care use in families with children who have PNES. The aim of the current study was to explore whether child coping and parental bonding styles influence the decision to seek urgent medical care in these families. Methods Data were analyzed from youth of age 8-18 years, 47 with PNES, and their 25 sibling controls. Parents provided the number of youth emergency room visits and hospitalizations in the preceding year. Youth completed a questionnaire about their coping styles and a measure about their mothers' and fathers' bonding styles. Using a mixed model with family as a random effect, we regressed urgent health-care use on participant type (youth with PNES or sibling), parental bonding style, and youth coping style, controlling for number of child prescription medications. Results Higher urgent health-care use was associated with having PNES, coping via monitoring, and perceiving one's father to be rejecting and overprotective. Lower urgent health-care use was associated with coping via venting and with perceiving one's mother to be caring and overprotective. Conclusions This study provides preliminary empirical support for family-based clinical efforts to reduce child urgent health-care use by enhancing effective child coping skills and improving parental response to child impairment and distress in families with youth with PNES.

Though posttraumatic epilepsy (PTE) is a prominent sequela of traumatic brain injury (TBI), other nonepileptic phenomena also warrant consideration. Within two UCLA pediatric TBI cohorts, we categorized five spell types: 1) PTE; 2) Epilepsy with other potential etiologies (cortical dysplasia, primary generalized); 3) Psychopathology; 4) Behavior misinterpreted as seizures; and 5) Other neurologic events. The two cohort subsets differed slightly in injury severity, but they were otherwise similar. Overall, PTE occurred in 40%, other epilepsy etiologies in 14%, and nonepileptic spells collectively in 46%. Among children with spells, PTE was associated with severe TBI (p=0.001), whereas psychopathology (p=0.014) and epilepsy with other etiologies (p=0.006) were associated with milder TBI severity. Posttraumatic epilepsy (p=0.002) and misinterpreted behavior (p=0.049) occurred with younger injury age. Psychopathology (p=0.020) and other neurologic events (p=0.002) occurred with older injury age. In evaluating possible PTE, clinicians should maintain a broad differential diagnosis to prevent misdiagnosis and inappropriate treatment.

Objectives This study examined the risk factors for learning problems (LP) in pediatric psychogenic non-epileptic seizures (PNES) and their specificity by comparing psychopathology, medical, cognitive/linguistic/achievement, bullying history, and parent education variables between subjects with PNES with and without LP and between subjects with PNES and siblings with LP. Methods 55 subjects with PNES and 35 siblings, aged 8–18 years, underwent cognitive, linguistic, and achievement testing, and completed somatization and anxiety sensitivity questionnaires. A semi-structured psychiatric interview about the child was administered to each subject and parent. Child self-report and/or parent report provided information on the presence/absence of LP. Parents also provided each subject's medical, psychiatric, family, and bullying history information. Results Sixty percent (33/55) of the PNES and 49% (17/35) of the sibling subjects had LP. A multivariable logistic regression demonstrated that bullying and impaired formulation of a sentence using a stimulus picture and stimulus word were significantly associated with increased likelihood of LP in the PNES youth. In terms of the specificity of the LP risk factors, a similar analysis comparing LP in the youth with PNES and sibling groups identified anxiety disorder diagnoses and bullying as the significant risk factors associated with LP in the PNES youth. Conclusions These findings emphasize the need to assess youth with PNES for LP, particularly if they have experienced bullying, have linguistic deficits, and meet criteria for anxiety disorder diagnoses.

Purpose To examine the risk factors for internalizing (anxiety, depression) and posttraumatic stress (PTSD) disorders, somatization, and anxiety sensitivity (AS) in youth with psychogenic non-epileptic seizures (PNES). Methods 55 probands with PNES and 35 siblings, aged 8–18 years, underwent a psychiatric interview, cognitive and language testing, and completed somatization and AS questionnaires. Parents provided the subjects' medical, psychiatric, family, and adversity history information. Results The risk factors for the probands' internalizing disorders (girls, older age of PNES onset), somatization (older age, epilepsy), and anxiety sensitivity (girls, adversities) differed from their siblings. The risk factors in the siblings, however, were similar to the general pediatric population. Proband depression was unrelated to the study's risk variables while PTSD was significantly associated with female gender and lower Full Scale IQ. Conclusions Knowledge about the specificity of the risk factors for comorbid psychopathology in youth with PNES might facilitate their early identification and treatment.

A diagnosis of childhood cancer is an unexpected event that can interrupt a child’s developmental trajectory. Palliative symptom management can improve quality of life as well as psychological, functional, and medical outcomes for a child who is coping with cancer. Within a larger framework of behavioral and family-based interventions, this chapter focuses on palliative psychopharmacological treatment recommendations for children with cancer. Sertraline, citalopram, or escitalopram should be considered first line for anxiety, PTSD, or depression. Risperidone or quetiapine can be an effective second-line adjunct for children with severe anxiety or trauma symptoms. Aggressive pain management with opiates can prevent iatrogenic trauma symptoms. Sleep problems may respond to melatonin, diphenhydramine, or trazodone. A low dose of quetiapine may treat insomnia due to delirium or severe anxiety. Risperidone is recommended for hypoactive/mixed delirium and haloperidol for hyperactive delirium.

Medically ill adolescents are at increased risk for psychological distress and/or functional impairment. However, there are few research studies examining the optimal psychiatric treatments for this population. Psychiatric medication recommendations are largely based on studies of youth with a primary psychiatric disorder, adult studies, hypothesized mechanisms of action, and/or clinical experience. This paper provides evidence-informed recommendations for the psychopharmacological treatment of acutely medically ill adolescents suffering from significant psychological distress and/or functional impairment. Representing the most common problems among medically ill adolescents that are treated with psychiatric medications, recommendations are provided for anxiety and depression; iatrogenic medical trauma, inadequate sleep and insomnia; and, delirium.

Medically ill children are often exposed to traumatizing situations within the medical setting. Approximately 25-30 % of medically ill children develop posttraumatic stress symptoms and 10-20 % of them meet criteria for posttraumatic stress disorder. Parents of medically ill children are at even higher risk for posttraumatic stress symptoms. Most children and parents will experience resolution of mild trauma symptoms without formal psychological or psychiatric treatment. Posttraumatic stress symptoms are associated with medical nonadherence, psychiatric co-morbidities, and poorer health status. Therefore, evidenced-based trauma-focused treatment is indicated for those who remain highly distressed or impaired. This paper reviews approaches to the assessment and management of pediatric iatrogenic medical trauma within a family-based framework.