Journal of the American Academy of Child & Adolescent Psychiatry

In This Issue/Abstract Thinking: When Is Bigger Better in Brain Development?

Carol M. Rockhill — 2012-02-01

The articles in this month's issue of the Journal juxtapose the progress in understanding neurobiology of psychiatric illness with new information about the treatment response to urgent psychiatric symptoms. Fox and Pine (p. 125) innovatively tested risk factors for development of anxiety disorders to examine underlying neurobiology. They highlight two recent studies showing that an attention bias to threat (measured by failing to keep attention on a working memory task under a perceived threat condition) helps to explain the link between early childhood behavioral inhibition and later social withdrawal. This research parallels the cognitive neuroscience model that perceived threats result in activation of the amygdala, followed by an adjustment of attention by the ventrolateral prefrontal cortex (PFC), which may be faulty in anxiety disorders. This line of research has led to a novel intervention of teaching self-modification of attention to threat, which is being tested to treat pediatric anxiety disorders.

Temperament and the Emergence of Anxiety Disorders

Nathan A. Fox, Daniel S. Pine — 2012-02-01

Anxiety disorders, among the most prevalent childhood psychiatric disorders, significantly impair current functioning and portend an increased risk for various problems in adolescence and adulthood. Therefore, studying risk factors is crucially important. One such risk factor is the child temperament of behavioral inhibition (BI). Children with this temperament are significantly more likely to develop anxiety disorders than children with other temperaments.

Friends Not Foes: Combined Risperidone and Behavior Therapy for Irritability in Autism

Thomas W. Frazier — 2012-02-01

Challenging behavior often requires a multifaceted treatment approach. The notion that only medication or behaviorial therapy would maximize the treatment of all irritable, autism-affected youth is simplistic, yet individual treatment remains the standard of practice in many settings, with clinicians relying on their most familiar tool. This trend is not surprising because the substantial literature on the effectiveness of behavioral intervention in treating irritable/aggressive behavior in autism has not been well advertised outside the intensive behavioral intervention community. Moreover, this work has not been shaped into a delivery system that would be suitable for less intensive outpatient settings. Similarly, the literature demonstrating the efficacy and effectiveness of atypical antipsychotic drugs is relatively recent and more familiar to psychiatrists than to behavioral therapists. New innovations are always slow to diffuse initially. The time has come to merge these distinct literatures and investigate the power of combined treatment approaches, particularly given the severity of the challenging behavior and functional impairment observed in these youth.

Cautious Reassurance: Cardiovascular Risk in the Context of Stimulant Use

Laurence L. Greenhill — 2012-02-01

Based on insurance claims data, 3.6 million children took stimulant medications for attention-deficit/hyperactivity disorder (ADHD) in 2008. Historically, stimulants have been considered safe for long-term use. However, the Food and Drug Administration's Adverse Event Reporting System, which collects postmarketing reports of adverse events, has identified cases of myocardial infarction, stroke, and sudden unexplained death in patients taking stimulant medication. Although dependent on uncontrolled, spontaneous reports, postmarketing surveillance is sensitive to rare or unusual adverse events. Although it cannot really identify causal links or quantify risk, it can provide compelling information. For example, postmarketing surveillance identified a number of cases of hepatic damage with pemoline, leading to the drug's removal from the market.

This Is Your Brain. This Is Your Brain on Treatment. Any Questions?

Daniel P. Dickstein — 2012-02-01

This month's Journal features an article by Pavuluri and colleagues that may herald the future of clinical practice, whereby treatment development is guided by brain imaging. Specifically, Pavuluri and colleagues sought to evaluate the effect of risperidone or divalproex on brain circuits mediating affect and working memory in children and adolescents with bipolar disorder (BD). To achieve this goal, they randomized youths with BD to receive risperidone plus placebo or divalproex plus placebo and conducted pre- and post-treatment functional magnetic resonance imaging (fMRI) scans.

Effects of Risperidone and Parent Training on Adaptive Functioning in Children With Pervasive Developmental Disorders and Serious Behavioral Problems

2011-12-26

Objective: Children with Pervasive Developmental Disorders (PDDs) have social interaction deficits, delayed communication, and repetitive behaviors as well as impairments in adaptive functioning. Many children actually show a decline in adaptive skills compared with age mates over time. Method: This 24-week, three-site, controlled clinical trial randomized 124 children (4 through 13 years of age) with PDDs and serious behavioral problems to medication alone (MED; n = 49; risperidone 0.5 to 3.5 mg/day; if ineffective, switch to aripiprazole was permitted) or a combination of medication plus parent training (PT) (COMB; n = 75). Parents of children in COMB received an average of 11.4 PT sessions. Standard scores and Age-Equivalent scores on Vineland Adaptive Behavior Scales were the outcome measures of primary interest. Results: Seventeen subjects did not have a post-randomization Vineland assessment. Thus, we used a mixed model with outcome conditioned on the baseline Vineland scores. Both groups showed improvement over the 24-week trial on all Vineland domains. Compared with MED, Vineland Socialization and Adaptive Composite Standard scores showed greater improvement in the COMB group (p = .01 and .05, and effect sizes = 0.35 and 0.22, respectively). On Age Equivalent scores, Socialization and Communication domains showed greater improvement in COMB versus MED (p = .03 and 0.05, and effect sizes = 0.33 and 0.14, respectively). Using logistic regression, children in the COMB group were twice as likely to make at least 6 months' gain (equal to the passage of time) in the Vineland Communication Age Equivalent score compared with MED (p = .02). After controlling for IQ, this difference was no longer significant. Conclusion: Reduction of serious maladaptive behavior promotes improvement in adaptive behavior. Medication plus PT shows modest additional benefit over medication alone. Clinical trial registration information–RUPP PI PDD: Drug and Behavioral Therapy for Children With Pervasive Developmental Disorders; http://www.clinicaltrials.gov; NCT00080145.

Stimulants and Cardiovascular Events in Youth With Attention-Deficit/Hyperactivity Disorder

2011-12-22

Objective: This study examined associations between stimulant use and risk of cardiovascular events and symptoms in youth with attention-deficit/hyperactivity disorder and compared the risks associated with methylphenidate and amphetamines. Method: Claims were reviewed of privately insured young people 6 to 21 years old without known cardiovascular risk factors (n = 171,126). A day-level cohort analysis evaluated the risk of cardiovascular events after a diagnosis of attention-deficit/hyperactivity disorder in relation to stimulant exposures. Based on filled stimulant prescriptions, follow-up days were classified as current, past, and no stimulant use. Endpoints included an emergency department or inpatient diagnosis of angina pectoris, cardiac dysrhythmia, or transient cerebral ischemia (cardiac events) or tachycardia, palpitations, or syncope (cardiac symptoms). Results: There were 0.92 new cardiac events and 3.08 new cardiac symptoms per 1,000,000 days of current stimulant use. Compared with no stimulant use (reference group), the adjusted odds ratios of cardiac events were 0.69 (95% confidence interval 0.42–1.12) during current stimulant use and 1.18 (95% CI 0.83–1.66) during past stimulant use. The corresponding adjusted odds ratios for cardiac symptoms were 1.18 (95% CI 0.89–1.59) for current and 0.93 (95% CI 0.71–1.21) for past stimulant use. No significant differences were observed in risks of cardiovascular events (2.14, 95% CI 0.82–5.63) or symptoms (1.08, 95% CI 0.66–1.79) for current methylphenidate use compared with amphetamine use (reference group). Conclusions: Clinical diagnoses of cardiovascular events and symptoms were rare and not associated with stimulant use. The results help to allay concerns over the cardiovascular safety of stimulant treatment for attention-deficit/hyperactivity disorder in young people without known pre-existing risk factors.

Risperidone and Divalproex Differentially Engage the Fronto-Striato-Temporal Circuitry in Pediatric Mania: A Pharmacological Functional Magnetic Resonance Imaging Study

2011-12-26

Objective: The current study examined the impact of risperidone and divalproex on affective and working memory circuitry in patients with pediatric bipolar disorder (PBD). Method: This was a six-week, double-blind, randomized trial of risperidone plus placebo versus divalproex plus placebo for patients with mania (n = 21; 13.6 ± 2.5 years of age). Functional magnetic resonance imaging (fMRI) outcomes were measured using a block design, affective, N-back task with angry, happy, and neutral face stimuli at baseline and at 6-week follow-up. Matched healthy controls (HC; n = 15, 14.5 ± 2.8 years) were also scanned twice. Results: In post hoc analyses on the significant interaction in a 3×2×2 analysis of variance (ANOVA) that included patient groups and HC, the risperidone group showed greater activation after treatment in response to the angry face condition in the left subgenual anterior cingulate cortex (ACC) and striatum relative to the divalproex group. The divalproex group showed greater activation relative to the risperidone group in the left inferior frontal gyrus and right middle temporal gyrus. Over the treatment course, the risperidone group showed greater change in activation in the left ventral striatum than the divalproex group, and the divalproex group showed greater activation change in left inferior frontal gyrus and right middle temporal gyrus than the risperidone group. Furthermore, each patient group showed increased activation relative to HC in fronto-striato-temporal regions over time. The happy face condition was potentially less emotionally challenging in this study and did not elicit notable findings. Conclusions: When patients performed a working memory task under emotional duress inherent in the paradigm, divalproex enhanced activation in a fronto-temporal circuit whereas risperidone increased activation in the dopamine (D2) receptor–rich ventral striatum. Clinical trial registration information—Risperidone and Divalproex Sodium With MRI Assessment in Pediatric Bipolar; http://www.clinicaltrials.gov; NCT00176202.

Parietal Lobe Volume Deficits in Adolescents With Schizophrenia and Adolescents With Cannabis Use Disorders

2011-12-15

Objective: In early-onset schizophrenia (EOS), the earliest structural brain volumetric abnormalities appear in the parietal cortices. Early exposure to cannabis may represent an environmental risk factor for developing schizophrenia. This study characterized cerebral cortical gray matter structure in adolescents in regions of interest (ROIs) that have been implicated in EOS and cannabis use disorders (CUD). Method: T1-weighted magnetic resonance images were acquired from adolescents with EOS (n = 35), CUD (n = 16), EOS + CUD (n = 13), and healthy controls (HC) (n = 51). Using FreeSurfer, brain volume was examined within frontal, temporal, parietal and subcortical ROIs by a 2 (EOS versus no EOS) × 2 (CUD versus no CUD) design using multivariate analysis of covariance. In ROIs in which volumetric differences were identified, additional analyses of cortical thickness and surface area were conducted. Results: A significant EOS-by-CUD interaction was observed. In the left superior parietal region, both ”pure” EOS and ”pure” CUD had smaller gray matter volumes that were associated with lower surface area compared with HC. A similar alteration was observed in the comorbid group compared with HC, but there was no additive volumetric deficit found in the comorbid group compared with the separate groups. In the left thalamus, the comorbid group had smaller gray matter volumes compared with the CUD and HC groups. Conclusions: These preliminary data indicate that the presence of a CUD may moderate the relationship between EOS and cerebral cortical gray matter structure in the left superior parietal lobe. Future research will follow this cohort over adolescence to further examine the impact of cannabis use on neurodevelopment.

Regional Cerebral Development at Term Relates to School-Age Social–Emotional Development in Very Preterm Children

2012-02-01

Objective: Preterm children are at risk for social–emotional difficulties, including autism and attention-deficit/hyperactivity disorder. We assessed the relationship of regional brain development in preterm children, evaluated via magnetic resonance imaging (MRI) at term-equivalent postmenstrual age (TEA), to later social–emotional difficulties. Method: MR images obtained at TEA from 184 very preterm infants (gestation <30 weeks or birth weight <1,250 g) were analyzed for white matter abnormalities, hippocampal volume, and brain metrics. A total of 111 infants underwent diffusion tensor imaging, which provided values for fractional anisotropy and apparent diffusion coefficient. Social–emotional development was assessed with the Infant Toddler Social and Emotional Assessment (ITSEA) at age 2 and the Strengths and Difficulties Questionnaire (SDQ) at age 5 years. Results: Higher apparent diffusion coefficient in the right orbitofrontal cortex was associated with social–emotional problems at age 5 years (peer problems, p < .01). In females, smaller hippocampal volume was associated with increased hyperactivity (p < .01), peer problems (p < .05), and SDQ total score (p < .01). In males, a smaller frontal region was associated with poorer prosocial (p < .05) scores. Many of the hippocampal findings remained significant after adjusting for birthweight z score, intelligence, social risk, immaturity at birth, and parental mental health. These associations were present in children who had social–emotional problems in similar domains at age 2 and those who did not. Conclusions: Early alterations in regional cerebral development in very preterm infants relate to specific deficits in social–emotional performance by school-age. These results vary by gender. Our results provide further evidence for a neuroanatomical basis for behavioral challenges found in very preterm children.

Prevalence of Tourette Syndrome and Chronic Tics in the Population-Based Avon Longitudinal Study of Parents and Children Cohort

Jeremiah M. Scharf, Laura L. Miller, Carol A. Mathews, Yoav Ben-Shlomo — 2011-12-26

Objective: Recent epidemiologic studies have demonstrated that Tourette syndrome (TS) and chronic tic disorder (CT) are more common than previously recognized. However, few population-based studies have examined the prevalence of co-occurring neuropsychiatric conditions such as obsessive-compulsive disorder (OCD) and attention-deficit/hyperactivity disorder (ADHD). We evaluated the prevalence of TS, CT, and their overlap with OCD and ADHD in the Avon Longitudinal Study of Parents and Children (ALSPAC) birth cohort. Method: A total of 6,768 children were evaluated using longitudinal data from mother-completed questionnaires. DSM-IV-TR diagnoses of TS and CT were derived using three levels of diagnostic stringency (Narrow, Intermediate, and Broad). Validity of the case definitions was assessed by comparing gender ratios and rates of co-occurring OCD and ADHD using heterogeneity analyses. Results: Age 13 prevalence rates for TS (0.3% for Narrow; 0.7% for Intermediate) and CT (0.5% for Narrow; 1.1% for Intermediate) were consistent with rates from other population-based studies. Rates of co-occurring OCD and ADHD were higher in TS and CT Narrow and Intermediate groups compared with controls but lower than has been previously reported. Only 8.2% of TS Intermediate cases had both OCD and ADHD; 69% of TS Intermediate cases did not have either co-occurring OCD or ADHD. Conclusions: This study suggests that co-occurring OCD and ADHD is markedly lower in TS cases derived from population-based samples than has been reported in clinically ascertained TS cases. Further examination of the range of co-occurring neuropsychiatric disorders in population-based TS samples may shed new perspective on the underlying shared pathophysiology of these three neurodevelopmental conditions.

Toward Brief “Red Flags” for Autism Screening: The Short Autism Spectrum Quotient and the Short Quantitative Checklist in 1,000 Cases and 3,000 Controls

Carrie Allison, Bonnie Auyeung, Simon Baron-Cohen — 2012-01-03

Objective: Frontline health professionals need a “red flag” tool to aid their decision making about whether to make a referral for a full diagnostic assessment for an autism spectrum condition (ASC) in children and adults. The aim was to identify 10 items on the Autism Spectrum Quotient (AQ) (Adult, Adolescent, and Child versions) and on the Quantitative Checklist for Autism in Toddlers (Q-CHAT) with good test accuracy. Method: A case sample of more than 1,000 individuals with ASC (449 adults, 162 adolescents, 432 children and 126 toddlers) and a control sample of 3,000 controls (838 adults, 475 adolescents, 940 children, and 754 toddlers) with no ASC diagnosis participated. Case participants were recruited from the Autism Research Centre's database of volunteers. The control samples were recruited through a variety of sources. Participants completed full-length versions of the measures. The 10 best items were selected on each instrument to produce short versions. Results: At a cut-point of 6 on the AQ-10 adult, sensitivity was 0.88, specificity was 0.91, and positive predictive value (PPV) was 0.85. At a cut-point of 6 on the AQ-10 adolescent, sensitivity was 0.93, specificity was 0.95, and PPV was 0.86. At a cut-point of 6 on the AQ-10 child, sensitivity was 0.95, specificity was 0.97, and PPV was 0.94. At a cut-point of 3 on the Q-CHAT-10, sensitivity was 0.91, specificity was 0.89, and PPV was 0.58. Internal consistency was >0.85 on all measures. Conclusions: The short measures have potential to aid referral decision making for specialist assessment and should be further evaluated.

Outpatient Care of Young People After Emergency Treatment of Deliberate Self-Harm

Jeffrey A. Bridge, Steven C. Marcus, Mark Olfson — 2011-12-26

Objective: Little is known about the mental health care received by young people after an episode of deliberate self-harm. This study examined predictors of emergency department (ED) discharge, mental health assessments in the ED, and follow-up outpatient mental health care for Medicaid-covered youth with deliberate self-harm. Method: A retrospective longitudinal cohort analysis was conducted of national 2006 Medicaid claims data supplemented with the Area Resource File and a Substance Abuse and Mental Health Services Administration Medicaid policy survey of state policy characteristics focusing on ED treatment episodes by youth 10 to 19 years old for deliberate self-harm (n = 3,241). Rates and adjusted risk ratios (ARR) of discharge to the community, mental health assessments in the ED, and outpatient visits during the 30 days after the ED visit were assessed. Results: Most patients (72.9%) were discharged to the community. Discharge was inversely related to recent psychiatric hospitalization (ARR 0.75, 99% confidence interval [CI] 0.63–0.90). Thirty-nine percent of discharged patients received a mental health assessment in the ED and a roughly similar percentage (43.0%) received follow-up outpatient mental health care. Follow-up mental health care was directly related to recent outpatient (ARR 2.58, 99% CI 2.27–2.94) and inpatient (ARR 1.33, 99% CI 1.14–1.56) mental health care and inversely related to Hispanic ethnicity (ARR 0.78, 99% CI 0.64–0.95) and residence in a county with medium-to-high poverty rates (ARR 0.84, 99% CI 0.73–0.97). Conclusions: A substantial proportion of young Medicaid beneficiaries who present to EDs with deliberate self-harm are discharged to the community and do not receive emergency mental health assessments or follow-up outpatient mental health care.

Guest Editor's Note

Laura M. Prager, Vaughn L. Mankey — 2012-02-01

In an era when cyber-bullying, sexting, violence, and the like occur with frequency among youth, many parents find themselves without a roadmap for instilling protective and enriching moral values in their children. Parents commonly struggle with how to provide salient and digestible moral guidance to their young ones amidst a sea of outside influences. Clinicians who work with at-risk youth are often called on by parents to assist in steering a child's ship through the murky waters of development toward a destination of good character, morality, and virtue. Reaching such a destination is not a quick or easy task, however. As Kohlberg has outlined, moral development occurs with increasing nuance and complexity over the life span. Clinicians who have limited “encounters” with families may also find themselves struggling to provide the amount of consistent guidance necessary. Therefore, having a manual of sorts, to which parents can refer, could be quite useful. However, knowing which “how-to” book to choose for parents can be a daunting endeavor. The reviewers in this Book Forum discuss a few potential options and share their insights although, admittedly, there is no one-size-fits-all text for such a complex issue. A common tenant in the selected books is that parents continue to be the most important contributors to their children's moral framework, and that modeling, experience, and dialogue are powerful teachers. Many of the writers also place an emphasis on the contrast between instant gratification and long-term fulfillment, and what parents can do to help promote the latter.

Cynthia Moore — 2012-02-01

A quick online search of books about rearing teenagers yields title after title that fit the formula, “Raising (blank) Teenagers: A Guide for Parents.” What fills the blank—self-reliant, thoughtful, spiritually mature, financially responsible, balanced, chaste, amazing, emotionally intelligent, happy, motivated, respectful, and self-sufficient, for example—reflects the range of virtues that parents hope to instill. The choice of title also reveals something of the author's frame of reference, and combined with a parent's values (and perhaps the adolescent's most glaring shortcomings), yields a short-list of reading options at least slightly more personalized than Amazon's “Recommended for You.”

Deborah Shelton — 2012-02-01

Richard and Linda Eyre have written numerous best-selling books advising parents on a variety of family life topics, including how to teach children about responsibility, sensitivity, sex, and lifestyle balance. Two new books have come out this year, The Entitlement Trap and 5 Spiritual Solutions for Everyday Parenting Challenges. Although Teaching Your Children Values was published in 1993, it continues to be relevant and worth reading.

Petra Steinbuchel — 2012-02-01

In these two books written for parents and other adults involved in teaching moral development to children, Richard Weissbourd and Robert Coles independently reference a story by Tolstoy: A little boy teaches his mother and father a parenting lesson and a lesson in empathy. His parents had recently made his grandfather start taking supper from a dishpan behind the stove instead of at the table with them because the aging grandfather has “broken too many dishes already” and was “spoiling everything.” The little boy lovingly makes a “dishpan” for his parents to eat from when they become old. Ashamed and weeping, the parents invite the grandfather back to the supper table and wait on him.

Editorial Board

2012-02-01

Council Page

2012-02-01

Journal of the American Academy of Child & Adolescent Psychiatry

In This Issue/Abstract Thinking: When Is Bigger Better in Brain Development?

Temperament and the Emergence of Anxiety Disorders

Friends Not Foes: Combined Risperidone and Behavior Therapy for Irritability in Autism

Cautious Reassurance: Cardiovascular Risk in the Context of Stimulant Use

This Is Your Brain. This Is Your Brain on Treatment. Any Questions?

Effects of Risperidone and Parent Training on Adaptive Functioning in Children With Pervasive Developmental Disorders and Serious Behavioral Problems

Stimulants and Cardiovascular Events in Youth With Attention-Deficit/Hyperactivity Disorder

Risperidone and Divalproex Differentially Engage the Fronto-Striato-Temporal Circuitry in Pediatric Mania: A Pharmacological Functional Magnetic Resonance Imaging Study

Parietal Lobe Volume Deficits in Adolescents With Schizophrenia and Adolescents With Cannabis Use Disorders

Regional Cerebral Development at Term Relates to School-Age Social–Emotional Development in Very Preterm Children

Prevalence of Tourette Syndrome and Chronic Tics in the Population-Based Avon Longitudinal Study of Parents and Children Cohort

Toward Brief “Red Flags” for Autism Screening: The Short Autism Spectrum Quotient and the Short Quantitative Checklist in 1,000 Cases and 3,000 Controls

Outpatient Care of Young People After Emergency Treatment of Deliberate Self-Harm

Guest Editor's Note

Editorial Board

Council Page

Table of Contents