Efficacy of paroxetine in the treatment of adolescent major depression: a randomized, controlled trial.

OBJECTIVE: To compare paroxetine with placebo and imipramine with placebo for the treatment of adolescent depression. METHOD: After a 7- to 14-day screening period, 275 adolescents with major depression began 8 weeks of double-blind paroxetine (20-40 mg), imipramine (gradual upward titration to 200-300 mg), or placebo. The two primary outcome measures were endpoint response (Hamilton Rating Scale for Depression [HAM-D] score < or = 8 or > or = 50% reduction in baseline HAM-D) and change from baseline HAM-D score. Other depression-related variables were (1) HAM-D depressed mood item; (2) depression item of the Schedule for Affective Disorders and Schizophrenia for Adolescents-Lifetime version (K-SADS-L); (3) Clinical Global Impression (CGI) improvement scores of 1 or 2; (4) nine-item depression subscale of K-SADS-L; and (5) mean CGI improvement scores. RESULTS: Paroxetine demonstrated significantly greater improvement compared with placebo in HAM-D total score < or = 8, HAM-D depressed mood item, K-SADS-L depressed mood item, and CGI score of 1 or 2. The response to imipramine was not significantly different from placebo for any measure. Neither paroxetine nor imipramine differed significantly from placebo on parent- or self-rating measures. Withdrawal rates for adverse effects were 9.7% and 6.9% for paroxetine and placebo, respectively. Of 31.5% of subjects stopping imipramine therapy because of adverse effects, nearly one third did so because of adverse cardiovascular effects. CONCLUSIONS: Paroxetine is generally well tolerated and effective for major depression in adolescents.

Bipolarity in children.

Childhood and adolescent bipolar disorder have been less studied than adult onset bipolar illness. However, case reports of mania in childhood can be found as early as the mid 19th century. Historically, several factors have made the accurate diagnosis of bipolar disorder in childhood difficult: clinical bias against the diagnosis of mania in children; low base rate of disorder; symptom overlap between bipolar disorder and other more prevalent childhood-onset psychiatric disorders; and developmental constraints and variability in clinical presentation. The epidemiology of juvenile-onset bipolar disorder remains an open topic for research. The disorder appears to increase in prevalence with advancing age until young adulthood. Reported phenomenology of bipolar disorder in children and adolescents indicates a highly variable presentation with a developmental trend towards increased resemblance to the adult phenotype with increasing age of onset. Diagnostic accuracy for the disorder is improved by adherence to diagnostic and statistical manual of mental disorders (DSM) criteria and may be aided by structured or semistructured diagnostic interviews. The course of bipolar disorder in children and adolescents has also received limited systematic study. However, research to date supports a clinical picture of a relapsing, recurrent illness with substantial morbidity. Systematic studies of pharmacologic treatments of acute mania in children and adolescents are limited in number and scope. Clinical justification for the use of acute antimanic treatments such as lithium and valproic acid is still based upon studies conducted in adults. There remains an immediate and significant need for additional research into all aspects of juvenile-onset bipolar disorder.

Comparison of lithium dosage methods for preschool- and early school-age children.

OBJECTIVE: Lithium may be useful in the treatment of prepubertal children with bipolar disorder or aggressive conduct disorder. However, there are few dosage guidelines. This study compares two dosage methods reported for prescribing lithium to prepubertal children: (1) a weight-based dosing schedule and (2) a single-dose, kinetics-based method. METHOD: Lithium doses were calculated using each method and then compared with doses actually used in the clinical care of hospitalized children. RESULTS: No statistically significant differences were found between mean lithium dose estimates calculated by the two methods. Average lithium dose estimates for both kinetic and weight-based methods were less than the observed discharge doses. Differences were seen between the two methods for children weighing between 25 and 30 kg. CONCLUSIONS: The weight-based dosing schedule and the single-dose, kinetics-based methods for calculating lithium dose result in similar dosage estimates when applied to young children.

Child temperament, parenting discipline style, and daytime behavior in childhood sleep disorders.

Fifty-two children without significant sleep disturbance seen at a primary care clinic for well-child care were compared on measures of temperament, parenting style, daytime behavior, and overall sleep disturbance to three diagnostic subgroups identified in a pediatric sleep clinic: children with obstructive sleep apnea (n = 33), parasomnias (night terrors, sleepwalking, etc.) (n = 16), and behavioral sleep disorders (limit-setting disorder, etc.) (n = 31). The mean age of the entire sample was 5.7 years. Temperamental emotionality in the behavioral sleep disorders group was associated with a higher level of sleep disturbance (p < .001); parenting laxness was associated with sleep disturbance in the general pediatric population (p < .01); and intense and negative temperament characteristics seemed to be associated with clinically significant behavioral sleep disturbances. Ineffective parenting styles and daytime disruptive behaviors were more likely to be associated with the milder sleep disturbances found in children in a primary care setting.

Somatoform disorders in children and adolescents: a review of the past 10 years.

OBJECTIVE: To review the literature on somatoform disorders in children and adolescents relevant to recertification by the American Board of Psychiatry and Neurology. METHOD: The psychiatric, pediatric, and psychological literatures were searched for clinical or research articles in the past 10 years dealing with somatization and somatoform disorders. RESULTS: Somatizing presentations are organized conceptually; somatization disorder, body dysmorphic disorder, hypochondriasis, conversion disorder, vocal cord dysfunction, pain disorder, and recurrent abdominal pain are described in children and adolescents; empirical evidence for treatment efficacy is scant, but clinically reasonable approaches are applied. CONCLUSION: More developmentally appropriate diagnostic schemas and better outcome studies are needed in all the somatoform disorders for children and adolescents.

Case study: hypersomnolence and precocious puberty in a child with pica and chronic lead intoxication.

The limited literature on hypersomnolence suggests that it is a poorly defined symptom associated with a spectrum of disorders from monosymptomatic hypersomnolence to the Kleine-Levin syndrome. These disorders often herald an organic central nervous system syndrome. Recent evidence suggests a frequent association between these disorders and hypothalamic dysfunction, which itself may be caused by a variety of factors. This case study of a patient with persistent hypersomnolence, hypothalamic dysfunction (in the form of precocious puberty), pica, and chronic lead intoxication strengthens the association between hypersomnolence and hypothalamic dysfunction and suggests a heretofore unreported cause of hypothalamic dysfunction in humans.

Untoward effects of lithium treatment in children aged four through six years.

OBJECTIVE: To explore the relationship between lithium dose and serum lithium level on the occurrence of untoward or toxic effects of lithium in the treatment of 20 hospitalized aggressive and/or mood-disordered children aged 4 through 6 years. METHOD: Clinical and research records of 20 children treated with lithium according to an established inpatient protocol were reviewed. Side effects as reported by psychiatric staff were categorized by organ system affected and severity. RESULTS: During the initial 2 weeks of lithium treatment, 60% of the children manifested one or more types of side effects, most commonly central nervous system effects. Side effects were seen at doses of 25.6 to 52.1 mg/kg per day and at serum levels from 0.65 to 1.37 mEq/L. In general, adverse effects were associated with higher lithium doses and lithium levels and were most common during the first week of treatment. A potential interaction between concurrent infection and more severe side effects was seen. CONCLUSIONS: Side effects occur frequently in children aged 6 years and younger during the initiation phase of lithium treatment; are related to higher milligram per kilogram doses, higher serum lithium levels, and phase of treatment; and may be related to concurrent medical illness.