Psychiatric concerns in pediatric epilepsy.

Pediatric epilepsy is a common, chronic, and challenging physical illness for children and their families. This article provides a medical overview and discusses the cognitive functioning and psychosocial adjustment as well as the psychiatric management for children and adolescents with pediatric epilepsy. The management of these children involves establishing a collaborative health care approach, evaluating academic functioning, considering psychotherapy, and managing psychopharmacologic treatment. A thorough understanding of the biopsychosocial concerns in pediatric epilepsy can enable medical providers and mental health clinicians to promote resiliency and adaptation in children and their families facing troubling seizure disorders.

Psychiatric concerns in pediatric epilepsy.

Pediatric epilepsy is a common, chronic, and challenging physical illness for children and their families. This article provides a medical overview and discusses the cognitive functioning and psychosocial adjustment as well as the psychiatric management for children and adolescents with pediatric epilepsy. The management of these children involves establishing a collaborative health care approach, evaluating academic functioning, considering psychotherapy, and managing psychopharmacologic treatment. A thorough understanding of the biopsychosocial concerns in pediatric epilepsy can enable medical providers and mental health clinicians to promote resiliency and adaptation in children and their families facing troubling seizure disorders.

Use of a virtual community as a psychosocial support system in pediatric transplantation.

Despite significant interest by pediatric transplant patients in meeting others who have undergone transplantation, geographic distances combined with their daily routines make this difficult. This mixed-method study describes the use of Zora, a Web-based virtual community designed to create a support system for these patients. The Zora software allows participants to create a graphical online virtual city with houses expressing their individuality and objects conveying their concerns and personal stories. Zora allows real-time chat between participants further facilitating communication. Twenty-two post-transplant patients used Zora over nine months. The median number of log ons per participant was 19.50 times (q1 = 5.25, q3 = 41.50), and each participant spent a median of 12.48 h (q1 = 2.13, q3 = 25.55) logged into the program. This represented a median of 18.27 min/wk (q1 = 6.88, q3 = 37.40) per participant. Users created a total of 3736 objects (median/participant = 12.5, q1 = 2.25, q3 = 30) and created 66 virtual houses (median/participant = 2.00, q1 = 1.00, q3 = 3.00). In addition, a total of 14,444 lines of chat were recorded (median/participant = 228.5, q1 = 30.00, q3 = 663.25), and a total 278 messages were sent between users (median/participant = 3.50, q1 = 0.25, q3 = 15.5). Qualitative data show the preliminary success of the project, as three major themes emerged: (i) increased sense of normalcy for the patients, (ii) enhanced sense of self and contribution to the community, and (iii) increased social network. There were no instances of harmful interactions in the virtual world. This study demonstrates the feasibility and safety of a virtual community as a potential psychosocial intervention for post-transplant adolescents.

Prospective open-label pilot trial of mirtazapine in children and adolescents with social phobia.

Mirtazapine is indicated for major depression and used for anxiety in adults; however, little is known about its application in pediatric populations. This is an 8-week open-label pilot study of mirtazapine in children with social phobia age 8-17 years. Primary outcomes were symptom improvement based on clinician rating and self-report, as well as tolerability based on rates of discontinuation due to adverse effects. Fifty-six percent (10/18) responded to treatment, 17% (3/18) achieved full remission. Social phobia symptoms improved significantly during the first 2 weeks of treatment, as did comorbid symptoms of depression and anxiety. Eleven patients (61%) did not complete all 8 weeks of treatment; four patients (22%) discontinued due to adverse effects including fatigue and irritability. The others discontinued due to study burden (28%), insufficient response (6%), or to pursue herbal treatment (6%). Significant weight gain was observed. Larger controlled trials are needed to further evaluate efficacy and safety.

A doubtful guest: managed care and mental health.

This article examines the ways in which mental health services have been affected by managed care and describes how to address some of the ethical conflicts that have always existed, but have been transformed immeasurably. It outlines the ethical dilemmas between the competing values of mental health providers and managed care, as well as the practical ethical considerations related to confidentiality, billing, and coding. It suggests that there can be no real improvement for mental health providers in the ethical minefield of managed care until they stop focusing on how distressed they are about it and start dealing with the larger, systemic issues in psychiatry and American health care. The article concludes by noting that the only way to effect meaningful change in the health care system is to combine knowledge with advocacy and to proactively define the standards needed to make the necessary choices.

Cognitive-behavioral therapy for adolescents with inflammatory bowel disease and subsyndromal depression.

OBJECTIVE: To examine the feasibility and efficacy of a manual-based cognitive-behavioral therapy (CBT) in reducing depressive symptomatology in adolescents with inflammatory bowel disease (IBD). Primary and Secondary Control Enhancement Therapy-Physical Illness (PASCET-PI) modified for youths with IBD was compared to treatment as usual (TAU), plus an information sheet about depression, without therapist contact using assessable patient analysis. METHOD: Following assessment, participants 11 to 17 years old with IBD and mild to moderate subsyndromal depression were randomly assigned to PASCET-PI (n = 22) or comparison treatment (n = 19). Primary outcome measures at baseline (T1) and 12 to 14 weeks posttreatment (T2) were Children's Depression Inventory (child/parent report), Schedule for Affective Disorders and Schizophrenia for School-Age Children (K-SADS), Children's Global Assessment Scale, and Perceived Control Scale for Children. RESULTS: The PASCET-PI group showed significantly greater improvement in Children's Depression Inventory (child/parent report), Children's Global Assessment Scale, and Perceived Control Scale for Children posttreatment than the comparison group. CONCLUSIONS: Screening and treatment of depressive symptoms in pediatric settings is feasible. PASCET-PI may be an efficacious intervention for subsyndromal depression in adolescents with IBD, although comparison with a more active treatment is necessary to attribute the improvement to PASCET-PI. CLINICAL TRIAL REGISTRATION INFORMATION: URL: http://clinicaltrials.gov. Unique identifier: NCT00446238.

Tolerability of selective serotonin reuptake inhibitors in thirty-nine children under age seven: a retrospective chart review.

OBJECTIVE: To characterize the adverse effects of treatment with selective serotonin reuptake inhibitors (SSRIs) started in children under age 7 yr. METHODS: We conducted a retrospective review of medical records for all children who had begun treatment with an SSRI under age 7 at an academic psychiatry department in Boston. RESULTS: Thirty-nine children (26 males, 13 females) met the inclusion criteria. Mean age at start of treatment was 5.9 +/- 0.8 yr, and median treatment duration was 5.0 months. The target diagnoses for SSRI treatment were anxiety disorders in 54%, depressive disorders in 23%, and both anxiety and depressive disorders in 20% of patients. There were no reports of suicidal ideation or attempt. No children were medically or psychiatrically hospitalized for adverse effects (AEs). Eleven patients (28%) reported an AE of at least moderate severity; 7 (18%) discontinued the SSRI due to the AE. Six patients discontinued due to behavioral activation and 1 due to gastrointestinal upset. The median time to onset of an AE was 23 days, and median resolution was 19 days from onset. CONCLUSIONS: The high rate of adverse effects, especially activation, in this sample argues for continued caution in using SSRIs in young children. Controlled trials are warranted.

Case study: longitudinal treatment of adolescents with depression and inflammatory bowel disease.

OBJECTIVE: To assess longitudinal maintenance of improvements in depression, anxiety, global functioning, and physical health perception in 11 adolescents at 6 and 12 months following completion of manual-based cognitive-behavioral therapy. METHOD: Standardized instruments assessed follow-up changes in depression, anxiety, physical health, and global psychological functioning. RESULTS: At both assessments, 10 adolescents did not meet criteria for mood disorders. Improvements in depression, anxiety, global functioning, and physical health perceptions at completion of the cognitive-behavioral therapy were maintained during the 12-month period. Additional cognitive-behavioral therapy sessions (mean = 4.36; SD = 4.37) and psychopharmacology (n = 5) were required during the follow-up period. CONCLUSIONS: CBT with maintenance sessions and medication offers promise to adolescents facing comorbid depressive and physical disorders.

Depression experience journal: a computer-based intervention for families facing childhood depression.

OBJECTIVE: This study tested the feasibility and safety of a computer-based application for families facing childhood depression. The Depression Experience Journal (EJ) is a psychoeducational intervention based on a narrative model involving the sharing of personal stories about childhood depression. METHOD: Semistructured interviews assessed Depression EJ feasibility and safety. Thirty-eight primary caretakers of children with depression (one caretaker per patient) used the EJ during a psychiatric hospitalization. Assessment of feasibility and safety was measured before EJ use and 2 to 4 weeks afterward. RESULTS: Results revealed that the EJ was safe and useful for decreasing social isolation, increasing hope, increasing understanding of familial feelings about childhood depression, and fostering positive reactions in caretakers. CONCLUSIONS: Computer-based interventions hold significant promise in providing a new manner of psychosocial support to families facing child and adolescent psychiatric illnesses.

Cognitive-behavioral therapy for depression in adolescents with inflammatory bowel disease: a pilot study.

OBJECTIVE: To evaluate the safety and feasibility of cognitive-behavioral therapy (CBT) for depression in physically ill adolescents. METHOD: In an open trial, 11 adolescents (12-17 years) with inflammatory bowel disease and either major or minor depression underwent 12 sessions of a manual-based CBT enhanced by social skills, physical illness narrative, and family psychoeducation components. Standardized instruments assessed pre- to posttreatment changes in depression, physical health, global psychological functioning, and social functioning. Perceived helpfulness and satisfaction with CBT were assessed. RESULTS: There were significant reductions in DSM-IV depression diagnoses and depressive symptoms and improvements in global psychological and social functioning. Adolescents' perceptions of their general health and physical functioning improved, although illness severity measures were unchanged. High subject satisfaction and helpfulness ratings for CBT were found along with no adverse events and high subject adherence. CONCLUSIONS: A manual-based CBT approach adapted to treat depression in physically ill adolescents appears to be a safe, feasible, and promising intervention.

The longitudinal impact of psychological functioning, medical severity, and family functioning in pediatric heart transplantation.

BACKGROUND: Few data are available on the longitudinal psychological functioning of patients after pediatric heart transplantation. The objective of this study was to determine whether pre-transplant psychological functioning, post-transplant medical severity, and family functioning relate to the psychological functioning of pediatric patients after heart transplantation. METHODS: The study included 23 patients who underwent heart transplantation between ages 3 and 20 years, survived at least 1 year after transplantation, and had been assessed previously after transplantation between 1993 and 1995. This study reports a second post-transplant assessment between 1999 and 2000. We assessed psychological functioning using the Children's Global Assessment Scale before and after heart transplantation. We assessed medical severity using the number of outpatient visits, hospitalizations, and biopsies and using the Side Effect Severity Scale. We used the Global Assessment of Family Relational Functioning Scale to rate family functioning. RESULTS: The majority of patients (15/23) were alive at the second follow-up. They had survived a median of 9.6 (6.1-12.9) years after transplantation. Similar to their first follow-up assessments, 73% demonstrated good psychological functioning after heart transplantation. Although we found no correlation between medical severity and post-transplant psychological functioning, we did find a significant correlation between family functioning during the first 2 years of transplantation and post-transplant emotional adjustment. CONCLUSIONS: The majority of children and adolescents have the capacity for healthy psychological functioning after heart transplantation. Nevertheless, ongoing psychological assessment and intervention is necessary for patients and their families who face pediatric heart transplantation because >25% probably will have emotional adjustment difficulties.

Psychosocial factors and quality of life in children and adolescents with implantable cardioverter-defibrillators.

Few data exist on the quality of life in children and adolescents with implantable cardioverter-defibrillators (ICDs). The objective of this study was to determine whether anxiety, depression, family functioning, and quality of life are related to cardiac illness severity in pediatric patients with ICDs. The subjects were 20 patients (mean age 14.8 years; median 15.1, range 9 to 19) who had an ICD implantation a mean 1.4 years (median 0.1, range 0 to 6) before the study. The patients completed the Revised Children's Manifest Anxiety Scale, Reynold's Adolescent/Child Depression Scales, Child Health Questionnaire-87, and the Worries About ICDs Scale. The parents completed the Impact-on-Family Scale and the Child Health Questionnaire (CHQ-50). The Defibrillator Severity Index assessed cardiac severity. The rates of anxiety or depression were not increased, although the patients appeared to experience a greater need for social acceptance. Parent ratings of overall family functioning did not differ significantly from normative sample means. Parents reported significantly lower CHQ-50 summary physical functioning scores than scores of a normative United States sample, whereas there was no significant difference for the CHQ-50 summary psychosocial score. Caregivers perceived that their children had a lower quality of life when asked about their child's physical functioning, functioning in the social-physical role, and general health perceptions. Despite the overall nonsignificance of the psychosocial summary score, the social emotional/behavioral role, and the emotional impact their child's health had on themselves, subscales were all significantly lower than the normative sample. Cardiac illness severity was not significantly associated with anxiety, depression, quality of life, or family functioning. However, significant associations were found among measures of anxiety, depression, family functioning, and quality of life. Overall, most pediatric patients with ICDs appear to be a resilient group of youngsters. Their quality of life was more strongly correlated with their feelings of anxiety and depression as well as their family functioning than to the severity of their cardiac illness.

Depression and anxiety in adults with congenital heart disease: a pilot study.

OBJECTIVE: To examine the presence of depression and anxiety in adults with congenital heart disease and the association of medical severity with depression and anxiety. DESIGN: Prospective, pilot study. SETTING: An adult outpatient cardiology clinic in university-affiliated children's hospital in Northeast. PATIENTS: Twenty-two adult patients with congenital heart disease followed in an adult cardiology clinic. Patients were selected who had no evidence of emotional or behavioral difficulties, (ie, no symptoms of depression or anxiety). Outcome Measures Standardized semi-structured psychiatric interview with structured checklist eliciting Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) diagnostic criteria for depressive and anxiety disorders, Brief Symptom Inventory (BSI), and the Cardiologist's Perception of Medical Severity scale. RESULTS: Among patients who had been assumed to be "well adjusted," 36.4% were experiencing a diagnosable psychiatric disorder, with anxiety or depressive symptoms being prominent. There were 6 patients (27.3%) who had BSI scores above 63 indicating pathological emotional functioning. There was significant convergent validity between the clinical diagnoses of depression and anxiety using both diagnostic interviews to identify DSM-IV diagnostic conditions and the BSI. There were significant associations between patient's medical severity scores and with the DSM-IV diagnosis of depression and the BSI global index score and depression subscale. CONCLUSIONS: This pilot study raises important concerns about the emotional functioning of many adults facing congenital heart disease, particularly those with complex lesions. From a clinical perspective, this work suggests that health care professionals should be alert for emotional difficulties and the possible need for psychological intervention for adult survivors of congenital heart disease even among those that are seemingly emotionally well adjusted.

Use of a computer-based application in a pediatric hemodialysis unit: a pilot study.

This report describes preliminary efforts to implement a computer-based application, called Zora, in a pediatric hemodialysis unit. The feasibility and safety of establishing a virtual community in the hemodialysis unit are explored. Zora allows users to design and inhabit a graphical virtual city where they create characters, stories and spaces while communicating in real-time. Over a 5-month period, 7 hemodialysis patients and 4 unit staff found Zora enjoyable and safe. The results support the premise that computational environments may offer an opportunity for pediatric patients and their caregivers to participate in virtual communities that promote coping with chronic physical illnesses.

Future of technology to augment patient support in hospitals.

This chapter explores the potential of using computer technology to support and augment psychotherapeutic interventions in hospitals, communities and homes. We describe two applications piloted at Children's Hospital Boston. The first pilot explored how patients with pediatric heart disease used the Storytelling Agent Generation Environment (SAGE) computer program to create interactive storytellers and share their personal stories. The second involved youngsters on hemodialysis for end stage renal disease using the Zora graphical multi-user environment to create a virtual city and form a therapeutic virtual community. In this chapter we show how computer technology can be used to help patients explore their identity, cope with their illness and provide mutual support and interaction. We also present design recommendations for future interventions of this kind.

A case series of eight aggressive young children treated with risperidone.

The aim of this study was to examine the use of risperidone in routine clinical care for very aggressive young children. This is a retrospective medical chart review of patients age less than 6 years 11 months who were treated with risperidone for 1 to 10 months during the 1-year study period. Treatment response, side effects, and Clinical Global Impression (CGI) scores were identified. One hundred and five such young children were identified; 8 had been treated with risperidone (6 boys, 2 girls: mean age 4.9 +/- 0.8 years). Risperidone was used in combination with other psychotropic medications in 7 of the 8 children. The mean daily dose of risperidone was 1.25 +/- 0.27 mg. Seventy-five percent of the children were on concomitant lithium, valproate, or carbamazepine; 63% were on stimulants or alpha adrenergics. This was a highly comorbid group, with 7 children presenting with attention deficit hyperactivity disorder and 5 children with bipolar disorder not otherwise specified. The average baseline CGI severity was 5.5 (SD = 0.5), and at last visit it was 3.5 (SD = 0.5), p < 0.0001. Mean CGI improvement score was 1.9 (SD = 0.6). Adverse effects included significant weight gain (mean 5.5 +/- 4.9 kg, p < 0.05) in 6 patients. One child had hyperprolactinemia. Given the potential development of atherosclerosis in obesity and endocrine response in hyperprolactinemia, risperidone should be reserved for those children with severe aggressive behavior who failed multiple trials with other agents. Further controlled trials are needed.

Staff groups in a pediatric hospital: content and coping.

The experience of staff members of a children's hospital, as presented in ward or staff groups, is considered. Staff meetings were initiated to share work-related concerns and feelings engendered by caring for hospitalized children. Significant stresses experienced by staff are described, and successful coping patterns are identified.