Adults with autism spectrum disorder: Updated considerations for healthcare providers.

Children with autism spectrum disorder (ASD) eventually grow up and need to make the transition from pediatric services to adult. This is a diverse patient population.

Patients with challenging behaviors: Communication strategies.

Some patients have behaviors that make interactions unpleasant, sometimes contributing to suboptimal outcomes and physician burnout. Understanding common difficult personality types can help doctors plan effective strategies for dealing with each, resulting in more effective communication, less stress, and better health outcomes.

Does Systemic Inflammation Play a Role in Pediatric Psychosis?

CONTEXT: Human and animal studies have suggested an underlying inflammatory mechanism for a variety of neuropsychiatric disorders, including schizophrenia. To date, most available reports focused on adult patients. OBJECTIVE: We wished to test the hypothesis that the first psychotic episode in youth is associated with inflammation. PATIENTS: We studied patients admitted to a pediatric inpatient psychiatric unit. Patients (n=80) had new-onset psychosis diagnosed using DSM-IV TR criteria for Psychosis NOS, Schizophreniform Disorder or Schizoaffective Disorder. Patients were matched for age, race and gender with inpatient controls without psychosis within the same unit (n=66). We also compared these values to normal pediatric hematologic values. To study the role of inflammation in youth with psychosis, we collected serum samples of 28 children presenting with first-episode psychosis and compared their serum cytokine and S100B levels to eight healthy controls. MAIN OUTCOME MEASURES: In this study, we measured serum markers of systemic inflammation. RESULTS: Leukocyte counts revealed a statistically significant increase in absolute monocytes compared to patients without psychosis (0.61 ± 0.282 k/ml vs. 0.496 ± 0.14 k/ml; p<0.01) and lymphocytes (2.51 ± 0.84 k/ml vs. 2.24 ± 0.72 k/ml; p<0.05) in patients with psychosis. All other hematologic values were similar between the groups. In addition, psychosis was characterized by increased serum levels of S100B, a peripheral marker of blood-brain barrier (BBB) damage. Several inflammatory mediators (e.g., TNF-α, IL-1ß, IL-6, IL-5, IL-10, and IFN-γ) were elevated in children with psychosis. CONCLUSIONS: These results strongly support a link between systemic inflammation, blood-brain barrier disruption and first-episode psychosis in pediatric patients.

Recognizing, managing medical consequences of eating disorders in primary care.

Eating disorders can lead to serious health problems, and as in many other disorders, primary care physicians are on the front line. Problems that can arise from intentional malnutrition and from purging affect multiple organ systems. Treatment challenges include maximizing weight gain while avoiding the refeeding syndrome.

Is an adult with Asperger syndrome sitting in your waiting room?

The prevalence of Asperger syndrome, a mild form of autism, appears to be rapidly increasing. This developmental disorder affects children and adults and can present challenges to providing medical care. In this update on Asperger syndrome, we offer guidance on how to interact with adult patients with the disorder. We also address proposed diagnostic changes scheduled to take effect in 2013.

Suicidal behavior in adolescents with first-episode psychosis.

BACKGROUND: Studies have reported an increased risk for suicide in adults with schizophrenia, but limited data on younger populations are available. AIMS: We hypothesize that first-episode psychosis is associated with an increased risk of suicidal behavior in adolescents. METHOD: A retrospective study was conducted with patients (n=102) diagnosed with psychosis not otherwised specified (NOS), schizophreniform disorder, schizoaffective disorder or schizophrenia within six months prior to admission. A control group consisting of ninety-eight patients with other (nonpsychosis) psychiatric diagnoses admitted to the same unit was matched by age, gender and ethnicity. All patients and controls were administered the Brief Psychiatric Rating Scale-Children version to assess severity of psychiatric symptoms and suicidality, and medical records were used to assess suicidal behavior and possible risk factors. RESULTS: When compared to controls, patients with psychosis had over twice as many suicide attempts overall (p<0.01). The 32% incidence of suicide attempts reported in this cohort is nearly double what is reported in adults with psychosis. Depressive symptoms were significantly correlated with increased suicide attempts (p<0.05). CONCLUSIONS: There was no significant difference between the number of pediatric psychosis inpatients versus nonpsychotic psychiatric inpatients who attempted suicide. There was, however, a significant difference between the total number of attempts between groups, illustrating that children and adolescents with psychosis are more likely than nonpsychotic psychiatric inpatients to have repeat, or multiple, suicide attempts. Longer duration of untreated psychosis, ADHD and depressive symptoms were found to be the strongest risk factors for patients with psychosis.

Serum S100B: a potential biomarker for suicidality in adolescents?

BACKGROUND: Studies have shown that patients suffering from depression or schizophrenia often have immunological alterations that can be detected in the blood. Others reported a possible link between inflammation, a microgliosis and the blood-brain barrier (BBB) in suicidal patients. Serum S100B is a marker of BBB function commonly used to study cerebrovascular wall function. METHODS: We measured levels of S100B in serum of 40 adolescents with acute psychosis, 24 adolescents with mood disorders and 20 healthy controls. Patients were diagnosed according to DSM-IV TR criteria. We evaluated suicidal ideation using the suicidality subscale of the Brief Psychiatric Rating Scale for Children (BPRS-C). RESULTS: Serum S100B levels were significantly higher (p<0.05) and correlated to severity of suicidal ideation in patients with psychosis or mood disorders, independent of psychiatric diagnosis. Patients with a BPRS-C suicidality subscores of 1-4 (low suicidality) had mean serum S100B values +/- SEM of 0.152+/-0.020 ng/mL (n = 34) compared to those with BPRS-C suicidality subscores of 5-7 (high suicidality) with a mean of 0.354+/-0.044 ng/mL (n = 30). This difference was statistically significant (p<0.05). CONCLUSION: Our data support the use of S100B as an adjunctive biomarker to assess suicidal risk in patients with mood disorders or schizophrenia.

Depression and heart disease: what do we know, and where are we headed?

Depression and heart disease have an intricate association and perhaps a causal relationship. We review the current status of depression and heart disease and provide an algorithm for diagnosing and treating depression in cardiac patients that internists and cardiologists can use in their daily patient encounters.

Identifying, evaluating, diagnosing, and treating ADHD in minority youth.

OBJECTIVE: This literature review describes evaluation and treatment of minority youth with ADHD. METHOD: A search of databases for reports of ADHD in minority children was conducted. RESULTS: Interpretation of behavior varies among parents, as does their trust in health care providers and school personnel. Parents desire to avoid stigmatization of their children from diagnostic labels and medications. They may not understand the sequelae of inadequate treatment or fear side effects of treatment. Children respond to stimulant medication but fare better when it is combined with regularly scheduled psychosocial treatment, including education and support for parents. Financial struggles affect access, evaluation, and treatment. Community support is desperately needed to gain parental trust. Creative planning allows health care providers and neighborhood leaders to join in, benefiting the children. CONCLUSION: Quality evaluation by a competent provider, careful choice of assessment tools, clear communication with parents, and close follow-up of progress are all needed.

Catatonia in adolescence: a case report.

The pathogenesis of catatonia is poorly understood and it can be fatal without effective treatment. Therefore, a swift diagnosis is necessary to treat this condition. It has been rarely described in children and adolescents. In a literature search, we have found only one reported case of excited catatonia described in a 16-year-old girl. In the following case report, we discuss a 16-year-old boy who presented with bipolar disorder-manic with catatonia. Through this case report, we hope to highlight some key points in the diagnosis and management of catatonia.

Review of adjunctive glutamate antagonist therapy in the treatment of catatonic syndromes.

Catatonia is a common neuropsychiatric syndrome which may arise from GABA-A hypoactivity, dopamine (D2) hypoactivity,and possibly glutamate NMDA hyperactivity. Amantadine and memantine have been reported as effective treatments for catatonia in selected cases, and probably mediate the presence of catatonic signs and symptoms through complex pathways involving glutamate antagonism. The authors identified 25 cases of catatonia treated with either agent. This article provides indirect evidence that glutamate antagonists may improve catatonic signs in some patients who fail to respond to established treatment, including lorazepam or electroconvulsive therapy. Further study of glutamate antagonists in the treatment of catatonia is needed.

Posttraumatic stress disorder in primary care patients.

Posttraumatic stress disorder (PTSD) is a common psychiatric condition. PTSD patients can present with a wide variety of symptoms, and these patients are also at a higher risk of other physical, psychiatric, and substance abuse problems. Recent advances in the treatment of this condition can help the majority of patients with PTSD. Early detection, initiation of appropriate treatment, and timely referral are crucial in the proper management of PTSD.

Psychiatric comorbidity in 36 adults with mitochondrial cytopathies.

INTRODUCTION: Mitochondria are intracellular organelles involved in adenosine triphosphate production. The literature has established the presence of mitochondrial dysfunction in some subjects with psychiatric disorders. Also, there are multiple reports of patients with mitochondrial dysfunction who have various psychiatric disorders. Although the literature on mitochondrial dysfunction and its relation to psychiatric disorders is growing, there remain many unanswered questions. OBJECTIVE: To review subjects with mitochondrial cytopathies for prevalence of psychiatric comorbidity. METHODS: For this study, 36 adults were interviewed. The Mini International Neuropsychiatric Interview and the Short-Form 36 Health Survey, version 1 were used. RESULTS: Lifetime diagnoses included 54% major depressive disorder, 17% bipolar disorder, and 11% panic disorder. These prevalence rates are compared with the general population and subjects with cancer and epilepsy. Subjects with a comorbid psychiatric diagnosis were older (P=.05), had more hospital admissions (P=.02), more medical conditions (P=.01), and lower quality of life (P=.01) than subjects with mitochondrial disease alone. CONCLUSION: Clinicians caring for persons with mitochondrial cytopathies should note the high prevalence of psychiatric problems. Also, this comorbidity might have etiological and therapeutic implications.

Deficits in diagnosis, treatment and continuity of care in African-American children and adolescents with ADHD.

Despite the evidence that attention-deficit/hyperactivity disorder (ADHD) is not just a diagnosis of whites, it often goes undiagnosed and is underresearched in the African-American population. There are higher rates of delinquency, incarceration, teen pregnancy and sexually transmitted diseases associated with inadequate or delayed treatment of ADHD. Afrcan Americans generally respond well to treatments, but access to evaluation, medication and psychotherapy is limited or absent for many, The purpose of this research is to compare descriptive characteristics of African-American children with ADHD to age-matched Caucasian children with the same diagnosis. Age at diagnosis, treatment offered, perception of outcome, adherence, comorbid symptoms and frequency of follow-up were collected retrospectively from charts of children treated in the sections of child and adolescent psychiatry and pediatric neurology.

Pharmacological treatment of neuropsychiatric symptoms of dementia: a review of the evidence.

STUDY DESIGN AND OBJECTIVE: Systemic review of double-blind, placebo-controlled, randomized controlled trials (RCTs) and meta-analyses of medication efficacy in the treatment of patients diagnosed with dementia and experiencing neuropsychiatric symptoms(hallucinations, delusions, agitation, aggression, combativeness, wandering). EXCLUSION CRITERIA: Studies were excluded if they reported only depression, if the medication was not available no longer used in the United States, or duplicated another study already included. DATA SOURCES: Medline of English articles between 1966 and June 2004, Cochrane Database of Systematic Reviews, and a manual search by the authors for other relevant articles. OUTCOMES: Diverse outcome measures ranging from global benefit to behavioral rating scales. Some of the 29 reports listed several instruments; in total, 24 rating scales were used. Statistical outcome was described and some, but not all, noted clinical impression. Adverse outcomes were listed. RESULTS: The results were clustered in groups: conventional antipsychotics, atypicals, antidepressants, cholinesterase inhibitors, mood stabilizers, and others. Treatment duration ranged from 17 days to 16 weeks. Types of dementia and levels of severity varied. The authors reported little benefit and some evidence for harm for typical (or conventional) agents. In contrast, some RCTs of atypical antipsychotics reported "modest" benefit, with olanzapine and risperidone leading others. Although trials reported minimal side effects at low doses, authors acknowledged an increased risk for stroke. No studies adequately compared benefit of typical with atypical agents. With the possible exception of citalopram, antidepressant agents did not reduce agitation, but did improve depression. Cholinesterase inhibiting agents demonstrated significant efficacy toward behavior, while memantine had mixed results. Valproate did not prove to be efficacious, and results for carbamazepine were conflicting.