Management of sleep disorders in autism spectrum disorder with co-occurring attention-deficit hyperactivity disorder: update for clinicians.

AIMS: To update and examine available literature germane to the recognition, assessment and treatment of comorbid autism spectrum disorder (ASD), attention-deficit hyperactivity disorder (ADHD) and sleep disruption, with a predominant focus on children, adolescents and emerging adults. BACKGROUND: Considerable overlaps exist among ASD, ADHD and sleep disruption. Literature and guidance for clinicians, administrators, policy makers and families have been limited, as such deliberations were rarely considered until 2013. METHOD: This narrative review of the literature addressing sleep disruption issues among those with ASD, ADHD and comorbid ASD and ADHD involved searching multiple databases and use of reverse citations up to the end of September 2022. Emphasis is placed on secondary sources and relevant data for clinical practice. RESULTS: Complex clinical presentations of ASD/ADHD/sleep disruption are frequently encountered in clinical practice. Prior to 2013, prevalence, clinical presentation, pathophysiology, prognosis, other sleep-related factors and interventions were determined separately for each disorder, often with overlapping objective and subjective methods employed in the process. High percentages of ADHD and ASD patients have both disorders and sleep disruption. Here, the extant literature is integrated to provide a multidimensional understanding of the relevant issues and insights, allowing enhanced awareness and better care of this complex clinical population. Database limitations are considered. CONCLUSIONS: Assessment of ASD symptomatology in youth with ADHD, and the reverse, in cases with disrupted sleep is critical to address the special challenges for case formulation and treatment. Evidence-based approaches to treatment planning and multi-treatment modalities should consider combining psychosocial and biological interventions to address the complexities of each case.

Focus on rural adolescent cannabis use and abuse: ignored epidemiologic trends, unique risks, long-term concerns, and hope.

Cannabis-related issues for adolescents and young adults are emerging from the shadow of rural opioid addiction and deaths. The rural pediatric population has multiple risk factors putting them at increased risk for adverse consequences with the expansion of cannabis legalization across the United States. Research in this area is rich but scattered across professional disciplines. Differences in demographics and cultures between rural and urban youth are gaining attention. Epidemiological factors relevant to rurality as a risk for cannabis and other substance use are considered for formulating clinical care, public policymakers, and future research. Race, culture, community stability, basic demographics of age, gender, educational status, and demands for more and better, accessible services for rural, nonmetropolitan areas comprise factors for consideration and are detailed. Research findings provide direction for policymakers and clinicians for prevention and intervention efforts to improve care for rural populations, validating and expanding upon insights gained to date.

Young migrant mental health difficulties and suicidal behaviours: an alternative perspective.

SummaryThe Saving and Empowering Young Lives in Europe (SEYLE) study brings attention to the special needs of adolescent migrants. Alternative data analyses could lead to improved service delivery and requisite education/training of health and mental health personnel. We advocate earlier identification by using SEYLE data to shape policy about youth suicidal behaviour and ideation in prevention efforts.Declaration of interestNone.

Aripiprazole for the treatment of schizophrenia with co-occurring social anxiety: an open-label cross-taper study.

OBJECTIVES: Co-occurring social anxiety in patients with schizophrenia is common and often severe. Pharmacologic agents with serotonin receptor 1A agonist properties such as aripiprazole are believed to be effective anxiolytic drugs. This open-label study tested the hypothesis that a switchover to aripiprazole would reduce the severity of social anxiety in patients, who have schizophrenia with co-occurring social anxiety, treated with neuroleptic medications. STUDY DESIGN: Eligible consenting outpatients meeting the criteria from the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, for schizophrenia or schizoaffective disorder with co-occurring social anxiety symptoms completed baseline assessments, after which their neuroleptic medication was gradually cross-titrated over to a maximum of 30 mg of aripiprazole orally per day. Patients who completed the 2-month short-term study had the option to continue for 10 more months in the extension phase of the study. Complete baseline assessments were performed after 1, 2, 4, 6, 9, and 12 months. The study hypothesized that a switchover to aripiprazole would significantly improve social anxiety symptoms and quality of life ratings in the short term and that treatment continuation would help maintain and strengthen those effects, as assessed on the Liebowitz Social Anxiety and Sheehan Disability scales and on preselected specific global items of the Lehman Quality of Life Interview. RESULTS: Sixteen patients were enrolled in the short-term study, and 10 of them entered the extension phase study. Last observation carried forward analysis showed significant improvements from baseline to the end of month 2 and from baseline to the end of month 12 in social anxiety scores (Liebowitz Social Anxiety Scale total, avoidance, and anxiety), social disability scores (Sheehan Disability Scale total, work, social life, and family), and in the Lehman Quality of Life Interview overall function, average life in general, and emotional well-being scores and psychosis (Positive and Negative Syndrome Scale total) scores. CONCLUSIONS: These findings suggest that the switchover to aripiprazole effectively improved social anxiety, psychosis, and quality of life in patients with schizophrenia who were treated with neuroleptic medications. These improvements occurred within the first 8 weeks of treatment and persisted when treatment was continued for up to 1 year. Further studies are warranted to replicate these findings in controlled trials.

Ethnicity and clinical psychiatric diagnosis in childhood.

This paper focuses on whether a consistent difference by ethnicity existed in the clinical diagnosis of children and adolescents in two behavioral health service environments and reviews plausible explanations for such a difference. Key measures were clinical diagnosis and ethnicity, abstracted from the administrative dataset of a New Jersey behavioral health care organization during 2000-2002, and a data collection conducted for the State of Indiana during 1991-1992. Sample sizes were 5,394 and 10,437, respectively. Only primary diagnoses were used in this study, classified into externalizing versus internalizing disorders. Logistic regression was performed for the dependent variable of presence/absence of an externalizing disorder or internalizing disorder. A main effect for ethnicity was found; African American youth received more externalizing diagnoses than did European American youth (odds ratio 2.01 (CI: 1.73-2.33) in one sample and 1.67 (CI: 1.44-1.94) in the other); African American youth also received fewer internalizing diagnoses than European American youth (odds ratio 0.55 (CI: .48-.63) in one sample and 0.75 (CI:.64-.88) in the other. Potential explanations for these findings include: 1. Biopsychosocial origin; 2. Clinician bias; 3. Discordant normative behavioral expectations between parents and service providers; and 4. Interaction between differential expression of underlying pathology and tolerance for such expressions.

A family study of alcohol dependence: coaggregation of multiple disorders in relatives of alcohol-dependent probands.

BACKGROUND: Alcohol dependence tends to aggregate within families. We analyzed data from the family collection of the Collaborative Study on the Genetics of Alcoholism to quantify familial aggregation using several different criterion sets. We also assessed the aggregation of other psychiatric disorders in the same sample to identify areas of possible shared genetic vulnerability. DESIGN: Age-corrected lifetime morbid risk was estimated in adult first-degree relatives of affected probands and control subjects for selected disorders. Diagnostic data were gathered by semistructured interview (the Semi-Structured Assessment for the Genetics of Alcoholism), family history, and medical records. Rates of illness were corrected by validating interview and family history reports against senior clinicians' all sources best estimate diagnoses. Sex, ethnicity, comorbidity, cohort effects, and site of ascertainment were also taken into account. RESULTS: Including data from 8296 relatives of alcoholic probands and 1654 controls, we report lifetime risk rates of 28.8% and 14.4% for DSM-IV alcohol dependence in relatives of probands and controls, respectively; respective rates were 37.0% and 20.5% for the less stringent DSM-III-R alcohol dependence, 20.9% and 9.7% for any DSM-III-R diagnosis of nonalcohol nonnicotine substance dependence, and 8.1% and 5.2% for antisocial personality disorder. Rates of specific substance dependence were markedly increased in relatives of alcohol-dependent probands for cocaine, marijuana, opiates, sedatives, stimulants, and tobacco. Aggregation was also seen for panic disorder, obsessive-compulsive disorder, posttraumatic stress disorder, and major depression. CONCLUSIONS: The risk of alcohol dependence in relatives of probands compared with controls is increased about 2-fold. The aggregation of antisocial personality disorder, drug dependence, anxiety disorders, and mood disorders suggests common mechanisms for these disorders and alcohol dependence within some families. These data suggest new phenotypes for molecular genetic studies and alternative strategies for studying the heterogeneity of alcohol dependence.

AACAP 2002 research forum: placebo and alternatives to placebo in randomized controlled trials in pediatric psychopharmacology.

OBJECTIVE: The use of placebo in the pediatric age group has come under increasing scrutiny. At the 2002 Annual Meeting of the American Academy of Child and Adolescent Psychiatry, the Academy's Workgroup on Research conducted a research forum. The purpose was to identify challenges and their solutions regarding the use of placebo in randomized controlled trials in pediatric psychopharmacology. METHOD: Workgroups focused on problems and solutions in five areas: ethics and human subjects, research design and statistics, partnering with consumers, U.S. Food and Drug Administration and pharmaceutical industry perspectives, and psychosocial treatments. RESULTS: In many but not all circumstances, inclusion of a placebo control is essential to meet the scientific goals of treatment outcome research. Innovative research designs; involvement of consumers in planning and implementing research; flexibility by industry, academia, the National Institutes of Health, and regulatory agencies acting in partnership; and concomitant use of evidence-based psychosocial services can and should assist in making placebo-controlled trials acceptable. CONCLUSIONS: Properly designed placebo-controlled trials remain necessary, ethical, and feasible.

Psychosocial variables in children and teens of extended families identified through bipolar affective disorder probands.

OBJECTIVES: This multi-site study investigated the frequency of risk-related variables for developing an affective disorder using a within-pedigree control group. We wished to determine the effect of life events, social relationships, self-perceived competence, and aspects of home environment for youngsters from extended families with loading for bipolar disorder. Using a within-family contrast group, we address the following two issues: (1) Do offspring or their parents from families who do and do not have an affected parent report differences (i) in home environment? (ii) in frequency and type of offspring life events? and (iii) in social relations and self-perception? and (2) Do children or their parents who do or do not have an affective disorder report differently on these areas? METHODS: Juvenile offspring (n = 50) and their parents from 14 bipolar pedigrees were assessed. Structured interviews and self- or parent-reported instruments were used to compare offspring with an affected first-degree relative to those without and to compare offspring with or without an affective disorder. RESULTS: Only one significant psychosocial difference was found between offspring with or without a parent with an affective disorder but several were found between offspring who themselves did or did not have an affective disorder. These differences are in the areas of the need for discipline, social support, and dependent negative life events. CONCLUSIONS: The findings identify potential early psychosocial markers for affective disorder in high risk offspring.

Intramuscular ziprasidone for acute agitation in adolescents.

Several neuropsychiatric disorders in children and adolescents often present with aggressive behavior. In fact, aggression is one of the most common reasons for psychiatric admission for inpatient hospitalization. Psychotropic medication can be helpful in reducing the need for more restrictive interventions, such as seclusion or restraint. The use of "as needed " (PRN) medications has been reported to decrease seclusion and restraint in a university-affiliated hospital setting. In our study, we report the cases of 3 youngsters whose escalating aggression responded to intramuscular ziprasidone with an immediate calming effect and good clinical outcome.

Adverse effects associated with physical restraint.

OBJECTIVE: Restraint use is not monitored in the US, and only institutions that choose to do so collect statistics. In 1999, investigative journalists reported lethal consequences proximal to restraint use, making it a life-and-death matter that demands attention from professionals. This paper reviews the literature concerning actual and potential causes of deaths proximal to the use of physical restraint. METHOD: Searching the electronic databases Medline, Cinahl, and PsycINFO, we reviewed the areas of forensics and pathology, nursing, cardiology, immunology, psychology, neurosciences, psychiatry, emergency medicine, and sports medicine. CONCLUSIONS: Research is needed to provide clinicians with data on the risk factors and adverse effects associated with restraint use, as well as data on procedures that will lead to reduced use. Research is needed to determine what individual risk factors and combinations thereof contribute to injury and death.

Developing strategies for psychopharmacological studies in preschool children.

OBJECTIVE: To identify the obstacles and special challenges-ethical, practical, scientific, and regulatory-faced by investigators who attempt to conduct psychopharmacological studies in preschoolers. METHOD: In a workshop held at the 47th Annual Meeting of the American Academy of Child and Adolescent Psychiatry, featuring interactive sessions designed to elicit discussion of the theory and feasibility of research in this young population, several key domains were identified: diagnosis and assessment, ethics, research design, special considerations for preschoolers, regulatory/industry issues, and education/training. RESULTS: A Pediatric Psychopharmacology Initiative is needed to consolidate recommendations from this and other workshops and current federal, research, and regulatory committees. A scholarly review and a guide for institutional review boards and investigators should be prepared on issues related to preschoolers. Developmental specialists provide valuable expertise that can strengthen studies of pediatric psychopharmacology. "N of 1" case studies can provide valuable information to clinicians. Only preschoolers with severe symptoms that occur in several interpersonal contexts should be entered into trials. Indications for the study of symptom complexes (e.g., aggression) rather than specific diagnoses should be examined and considered for regulatory activities. Psychopharmacology practice parameters for preschoolers are needed. CONCLUSIONS: With preschoolers being increasingly treated with psychopharmacological agents, the need for investigations to address the safety and efficacy of these medications is becoming a central issue for researchers from many disciplines.

Perceptions of P.R.N. psychotropic medications by hospitalized child and adolescent recipients.

OBJECTIVE: To understand patient perceptions of p.r.n. medication for agitation used in institutional settings. METHOD: A questionnaire was administered to child and adolescent psychiatric inpatients within 12 hours of their receiving p.r.n. medication for agitation and repeated 4 hours later. Research staff completed a form to rate each patient's comprehension and behavior in completing the questionnaire. RESULTS: Forty-two patients completed the survey: 38 males and 4 females, aged 7 to 17 years (mean age 12.19 years, median age 12 years). Patients requested the p.r.n. medication in 30% of episodes and assisted with the decision in an additional 10%. The p.r.n. was perceived for loss of control in more than half the cases. About 50% of the youngsters felt that the p.r.n. they received was the "best" for them. Only 30% answered that "something" could have been done by themselves or by staff to avoid requiring a p.r.n. medication. About 65% felt that "something good" happened from receiving the medication. The test-retest reliability of all but one question by kappa statistic was p