Faculty Bibliography

REASONS: Schizophrenia is typically an adult neurodevelopmental disorder that has its antecedents in childhood and adolescence. Little is known about disorders 'usually first diagnosed in infancy, childhood and adolescence' (e.g., childhood-onset disorders) in 'prodromal' teens at heightened clinical risk for psychotic disorder. MAIN FINDINGS: Childhood-onset disorders were prevalent in putatively prodromal teens, including anxiety and disruptive disorders, attention-deficit/hyperactivity disorder (ADHD), and, surprisingly, elimination disorders. These may reflect developmental antecedents in psychotic disorders such as schizophrenia. KEY DATA AND STATISTICS: A case series of 9 teens (ages 13-17) identified as prodromal to psychosis were evaluated with the Kiddie Schedule for Affective Disorders and Schizophrenia-Present and Lifetime Version (K-SADS-PL). Childhood-onset diagnoses commonly endorsed (threshold or subthreshold) included ADHD (5/9), oppositional defiant disorder (5/9), enuresis or encopresis (4/9), conduct disorder (2/9), separation anxiety (3/9), and transient tic disorder (2/9). Enuresis was identified in 3 of the 4 older teens (ages 15-17). MAJOR CONCLUSIONS: An understanding of the childhood-onset disorders that occur in teens at risk for psychotic illnesses, such as schizophrenia, can shed light on the pathophysiology of schizophrenia and potentially inform early identification and intervention

BACKGROUND: Although schools are often the first institutions to provide recovery efforts for children post-disaster, few studies have involved the school community in research to improve the delivery of these mental health services on campuses. This community-partnered study explores post-disaster counseling services 10 months following Hurricane Katrina. METHODS: In July 2006, nine focus groups, consisting of 39 school-based mental health counselors and six program administrators (10 men, 35 women), were conducted following a 2-day clinical training regarding a youth trauma intervention following Hurricane Katrina. Participants discussed the types of services they had been providing prior to the training and potential barriers to delivering services. RESULTS: Participants identified high mental health needs of students and described populations that did not seem to be adequately supported by current funding sources, including those with pre-existing traumatic experiences and mental health issues, indirect psychological and social consequences of the storms, and those students relocated to communities that were not as affected. Participants also described the need for a centralized information system. CONCLUSIONS: Participants described the need for greater organizational structure that supports school counselors and provides system-level support for services. Implications for next steps of this community-partnered approach are described.

OBJECTIVE: The aim of this study was to conduct a prospective safety and tolerability study of aripiprazole for the treatment of tics in children and adolescents with Tourette's disorder (TD). METHOD: Eleven subjects (10 males) with TD (age 9-19 years, mean 13.36, standard deviation [SD] 3.33) who did not respond or were unable to tolerate previous tic medication were treated with aripiprazole in an open-label, flexible-dosing study over 10 weeks. Tic severity was rated using the Yale Global Tic Severity Scale (YGTSS) and the Clinical Global Impressions Scale for tics (CGI-Tics) at baseline and at follow-up. RESULTS: The mean (+/-SD) daily dose for aripiprazole was 4.5 +/- 3.0 mg. Mean (+/-SD) YGTSS Global Severity scores reduced from 61.82 +/- 13.49 at baseline to 33.73 +/- 15.18 at end point; mean YGTSS total tic scores reduced from 28.18 +/- 7.74 at baseline to 16.73 +/- 7.54 at end point. Mean (+/-SD) CGI-Tic severity scores reduced from 4.45 +/- 0.52 (moderate-marked) at baseline to 3.18 +/- 0.60 (mild) at end point. On the CGI-Tic improvement scale, 10 (91%) subjects achieved 1 ('very much improved') or 2 ('much improved') at end point. Most common adverse effects included appetite increase and weight gain in 5 subjects, mild extrapyramidal effects in 7 subjects, and headaches and tiredness/fatigue in 7 subjects; 1 subject experienced akathisia and muscle cramps. CONCLUSION: Aripiprazole appears to be a safe and tolerable treatment in children and adolescents with TD that appears to reduce tics; it should be further investigated as a treatment option in controlled trials

This study examined media viewing by mothers with violence-related posttraumatic stress disorder (PTSD) and related media exposure of their preschool-age children. Mothers (N = 67) recruited from community pediatric clinics participated in a protocol involving a media-preference survey. Severity of maternal PTSD and dissociation were significantly associated with child exposure to violent media. Family poverty and maternal viewing behavior were also associated. Maternal viewing behavior mediated the effects specifically of maternal PTSD severity on child exposure. Clinicians should assess maternal and child media viewing practices in families with histories of violent trauma exposure and related psychopathology.

BACKGROUND: Anxiety disorders are characterized by elevated, sustained responses to threat, that manifest as threat attention biases. Recent evidence also suggests exaggerated responses to incentives. How these characteristics influence cognitive control is under debate and is the focus of the present study. METHODS: Twenty-five healthy adolescents and 25 adolescents meeting DSM-IV diagnostic criteria for an anxiety disorder were compared on a task of response inhibition. Inhibitory control was assayed with an antisaccade task that included both incentive (monetary reward) and incidental emotion (facial expression) cues presented prior to the execution of inhibitory behavior. RESULTS: Inhibitory control was enhanced following exposure to threat cues (fear faces) only in adolescent patients, and following exposure to positive cues (happy faces) only in healthy adolescents. Results also revealed a robust performance improvement associated with monetary incentives. This incentive effect did not differ by group. No interaction between incentives and emotional cues was detected. CONCLUSIONS: These findings suggest that biased processing of threat in anxious adolescents affects inhibitory control, perhaps by raising arousal prior to behavioral performance. The absence of normalization of performance in anxious adolescents following exposure to positive emotional cues is a novel finding and will require additional exploration. Future studies will need to more specifically examine how perturbations in positive emotion processes contribute to the symptomatology and the pathogenesis of anxiety disorders.

BACKGROUND:Accurate measures of the severity of pandemic (H1N1) 2009 influenza (pH1N1) are needed to assess the likely impact of an anticipated resurgence in the autumn in the Northern Hemisphere. Severity has been difficult to measure because jurisdictions with large numbers of deaths and other severe outcomes have had too many cases to assess the total number with confidence. Also, detection of severe cases may be more likely, resulting in overestimation of the severity of an average case. We sought to estimate the probabilities that symptomatic infection would lead to hospitalization, ICU admission, and death by combining data from multiple sources. METHODS AND FINDINGS/RESULTS:We used complementary data from two US cities: Milwaukee attempted to identify cases of medically attended infection whether or not they required hospitalization, while New York City focused on the identification of hospitalizations, intensive care admission or mechanical ventilation (hereafter, ICU), and deaths. New York data were used to estimate numerators for ICU and death, and two sources of data--medically attended cases in Milwaukee or self-reported influenza-like illness (ILI) in New York--were used to estimate ratios of symptomatic cases to hospitalizations. Combining these data with estimates of the fraction detected for each level of severity, we estimated the proportion of symptomatic patients who died (symptomatic case-fatality ratio, sCFR), required ICU (sCIR), and required hospitalization (sCHR), overall and by age category. Evidence, prior information, and associated uncertainty were analyzed in a Bayesian evidence synthesis framework. Using medically attended cases and estimates of the proportion of symptomatic cases medically attended, we estimated an sCFR of 0.048% (95% credible interval [CI] 0.026%-0.096%), sCIR of 0.239% (0.134%-0.458%), and sCHR of 1.44% (0.83%-2.64%). Using self-reported ILI, we obtained estimates approximately 7-9 x lower. sCFR and sCIR appear to be highest in persons aged 18 y and older, and lowest in children aged 5-17 y. sCHR appears to be lowest in persons aged 5-17; our data were too sparse to allow us to determine the group in which it was the highest. CONCLUSIONS:These estimates suggest that an autumn-winter pandemic wave of pH1N1 with comparable severity per case could lead to a number of deaths in the range from considerably below that associated with seasonal influenza to slightly higher, but with the greatest impact in children aged 0-4 and adults 18-64. These estimates of impact depend on assumptions about total incidence of infection and would be larger if incidence of symptomatic infection were higher or shifted toward adults, if viral virulence increased, or if suboptimal treatment resulted from stress on the health care system; numbers would decrease if the total proportion of the population symptomatically infected were lower than assumed.

Atypical features were incorporated into the American Psychiatric Association's Diagnostic and Statistical Manual, Fourth Edition (DSM-IV, 1994) as an illness specifier for major depression and dysthymia. The validity of depression with atypical features was supported by differences relative to depression with melancholic features in syndromal symptoms, course of illness, biology, family history, and treatment response. This paper reviews post-DSM-IV literature relevant to the validity of depression with atypical features. Most studies support the pre-DSM-IV findings. Again, course of illness, biological, family, and treatment differences are shown between melancholia and depression with atypical features. Several biologic studies report nondepressed controls have mean values between depressed subjects having atypical features and other depressed patients. This suggests atypical depression is a distinct depressive group rather than a milder form of melancholia. In addition, some studies show distinctions between depressed subjects with atypical features and those having neither atypical nor melancholic features. As depression with atypical features separates not only from melancholia but also from other depressed groups and controls over a range of meaningful distinctions, we conclude it is a valid clinical syndrome, useful both heuristically and in driving treatment decisions.

OBJECTIVE: Many children with pervasive developmental disorders (PDDs) have serious, functionally impairing behavioral problems. We tested whether combined treatment (COMB) with risperidone and parent training (PT) in behavior management is superior to medication alone (MED) in improving severe behavioral problems in children with PDDs. METHOD: This 24-week, three-site, randomized, parallel-groups clinical trial enrolled 124 children, aged 4 through 13 years, with PDDs, accompanied by frequent tantrums, self-injury, and aggression. The children were randomized 3:2 to COMB (n = 75) or MED (n = 49). The participants received risperidone monotherapy from 0.5 to 3.5 mg/day (with switch to aripiprazole if risperidone was ineffective). Parents in the COMB group (n = 75; 60.5%) received a mean of 10.9 PT sessions. The primary measure of compliance was the Home Situations Questionnaire (HSQ) score. RESULTS: Primary: intent-to-treat random effects regression showed that COMB was superior to MED on HSQ (p = .006) [effect size at week 24 (d) = 0.34]. The HSQ score declined from 4.31 (+/- 1.67) to 1.23 (+/- 1.36) for COMB compared with 4.16 (+/- 1.47) to 1.68 (+/- 1.36) for MED. Secondary: groups did not differ on Clinical Global Impressions-Improvement scores at endpoint; compared with MED, COMB showed significant reductions on Aberrant Behavior Checklist Irritability (d = 0.48; p = .01), Stereotypic Behavior (d = 0.23; p = .04), and Hyperactivity/Noncompliance subscales (d = 0.55; p = .04). Final risperidone mean dose for MED was 2.26 mg/day (0.071 mg/kg), compared with 1.98 mg/day for COMB (0.066 mg/kg) (p = .04). CONCLUSIONS: Medication plus PT resulted in greater reduction of serious maladaptive behavior than MED in children with PDDs, with a lower risperidone dose