Emotional expression during attention-deficit/hyperactivity disorders treatment: initial assessment of treatment effects.

OBJECTIVE: The purpose of this research was to provide an initial examination of the effects of atomoxetine and stimulants on emotional expression using a newly developed scale for assessing emotional expression in children with attention-deficit/hyperactivity disorder (ADHD). METHOD: The parent-rated Expression and Emotion Scale for Children (EESC) was collected during two studies. During a cross-sectional validation study, the EESC was completed to assess the child's current treatment and retrospectively for previous medication. In a randomized, placebo-controlled trial of atomoxetine, the EESC was collected at baseline and endpoint. RESULTS: In the validation study, no statistically significant differences in EESC scores were found between groups taking atomoxetine (n = 74) and stimulants (n = 105). Patients who switched from a stimulant to atomoxetine (n = 40) had greater improvement in emotional expression than those switched to another stimulant (n = 21) (p = 0.008). In the clinical trial, no difference in rates of worsening of emotional expression were observed (atomoxetine 8.8%, placebo 12.3%; p = 0.440). CONCLUSION: No treatment differences in emotional expression were observed based on current medications. However, stimulant patients needing to switch medications may have greater improvements in emotional expression by switching to atomoxetine.

Efficacy and safety of atomoxetine in childhood attention-deficit/hyperactivity disorder with comorbid oppositional defiant disorder.

OBJECTIVE: To compare the safety and efficacy of atomoxetine, a selective inhibitor of the norepinephrine transporter, versus placebo in Attention-Deficit/Hyperactivity Disorder (ADHD) patients with comorbid Oppositional Defiant Disorder (ODD). METHODS: A subset analysis of 98 children from two identical, multi-site, double-blind, randomized, placebo-controlled trials involving 9 weeks of treatment with atomoxetine or placebo was conducted. Patients met DSM-IV ADHD criteria. ODD was diagnosed with the Diagnostic Interview for Children and Adolescents-IV (DICA-IV; Reich, Weiner, and Herjanic, 1997). ADHD severity was assessed with the ADHD Rating Scale-IV-Parent Version: Investigator Administered and Scored (ADHD-RS-IV-Parent:lnv; DuPaul, Power, Anastopoulos, and Reid, 1998); the short version of the Conners' Parent Rating Scales-Revised (CPRS-R:S; Conners, 2000); and the Clinical Global Impressions of ADHD Severity (CGI-ADHD-S; Guy, 1976). Clinical response was defined as a > or = 25% reduction in ADHD-RS-IV-Parent:lnv total score. RESULTS: ADHD-RS-IV-Parent:lnv, CGI-ADHD-S, and three CPRS-R:S subscale scores improved markedly with atomoxetine treatment. However, a decrease in the CPRS-R:S Oppositional subscore for atomoxetine-treated patients was not significantly greater than scores for placebo-treated patients. Clinical response rates were 65.4% in the atomoxetine group, and 36.4% in the placebo group (p = .007). CONCLUSION: Atomoxetine was effective for the treatment of ADHD in patients with comorbid ODD. It did not significantly reduce the severity of ODD symptoms, and was well tolerated by the patients.

Consumer satisfaction at a child and adolescent state psychiatric hospital.

OBJECTIVE: This study examined satisfaction with services among patients in a child psychiatric hospital and their parents, and assessed the relationship between consumer satisfaction and the perception of improvement in the problem that led to hospitalization. METHODS: A consumer satisfaction survey developed by the investigators was administered to three sampling waves of child and adolescent psychiatric inpatients (N=157) and their parents or guardians (N=111). Ninety-five percent of patients contacted and 97 percent of their parents or guardians agreed to participate in the study. The survey provided data about the children's and parents' satisfaction with inpatient care and their perceptions of the children's clinical improvement. RESULTS: Most parents and children reported high satisfaction with patient care. Twenty-eight percent of children and 21 percent of parents reported some form of abuse by the staff during the hospital stay. Those who reported abusive behavior were significantly less satisfied with the hospital experience than those who did not report abuse. The participants' perception of clinical improvement was only weakly related to their satisfaction. CONCLUSIONS: Most child psychiatric patients and their parents will participate in consumer satisfaction surveys about inpatient care. Consumers are critical of a hospital if specific prompts in the survey are provided. An unexpectedly high level of consumer-reported abuse was found. Consumer-perceived clinical improvement was only weakly related to satisfaction.

The use of prn and stat medication in three child psychiatric inpatient settings.

As part of a larger study of prescribing practices in inpatient child and adolescent settings, 1,117 stat (emergency) and pm (as needed) doses administered to 150 child and adolescent inpatients at a state hospital, a private hospital, and a county-university hospital in the New York metropolitan area during 1991 were examined. Stat dosing was most common (p < .001) at the state hospital, where 76 percent of the medicated sample received at least one stat dose of medication; prn dosing was most common (p < .001) at the county-university hospital, where 80 percent of the medicated sample received at least one prn dose. Antihistamines were the most frequently used stat and prn medications at the state hospital. Antipsychotics were the most frequently used stat and prn medications at the private hospital. At the county-university hospital, the most frequently used stat medications were the minor tranquilizers, and the most frequently used prn medications were the antipsychotics. At all three hospitals, a high proportion of patients receiving stat or prn antipsychotics were receiving standing antipsychotics. At all three hospitals agitation was the predominant indication for stat or prn medication of any type.

Prescribing practices of inpatient child psychiatrists under three auspices of care.

To study prescribing practices of inpatient child psychiatrists under 3 auspices of care, 137 medicated patients were compared to 122 nonmedicated patients at a state hospital, a private hospital and a county-university hospital in New York during 1991. Overall, 79% of state, 76% of private, and 68% of county-university hospital patients received at least one dose of psychotropic medication, with the state versus county-university comparison significant (p < 0.05). Significantly more medicated patients at the private hospital (80%) than at the state or county-university hospitals (each 26%) received antidepressants (p's < 0.001). Significantly more county-university (74%) than private (35%) patients received antipsychotic medications, but the proportion of nonpsychotic patients receiving antipsychotic medication was statistically similar across the three hospitals. In nonpsychotic patients, antipsychotic agents were used to treat aggressive behavior. Patients 12 years of age or younger received more stimulants, and patients 13 years of age or older received more lithium (p's < 0.01). In a clinical review of medical charts of medicated patients from the 3 auspices of care, approximately 90% of the medication-treated patients were treated at an acceptable dose level and with an acceptable rationale based on symptom or diagnosis. These and other findings and other suggest that children in state hospitals are not over-medicated in comparison to children in private hospitals or university-county hospitals, and that prescribing practices among the three hospitals, despite their different funding sources, are comparable.

Soft signs in children of parents with agoraphobia.

OBJECTIVE: To study a proposed relationship between anxiety disorders and neurological soft signs by determining whether children of agoraphobic parents would have an increased prevalence of soft signs compared to children of parents without agoraphobia. METHOD: Family study methodology was used to compare 25 children of agoraphobic adults and 25 age- and sex-matched children of nonagoraphobic adults on a structured soft signs examination and on structured psychiatric interviews. Also, soft signs of 12 agoraphobic adults were compared with soft signs of 16 control adults. RESULTS: Children of agoraphobic adults had significantly more right- and left-side motor slowness on finger tapping and hand patting (p values < .05) than did children of controls. Seventy-six percent of the children of agoraphobic adults had at least one slow motor sign, compared with 28% of the control children (p < .001). There were no significant differences in soft signs between agoraphobic and control adults. CONCLUSIONS: The study provides additional support for a relationship between soft signs and anxiety disorder.

Prescribing practices of outpatient child psychiatrists.

OBJECTIVE: This study was designed to assess outpatient child psychiatrists' prescribing practices. METHOD: Of 1,422 outpatients in two public, university affiliated settings in New York and Ohio, the charts of 146 medicated and 126 nonmedicated randomly selected patients were reviewed for demographic variables, DSM-III-R diagnoses, medications prescribed, and charted prescription rationales. RESULTS: Fifteen percent of the 800 outpatients seen in a 1-month period in New York, and 19% of the 626 outpatients seen in a 1-year period in Ohio were prescribed medication. Patients medicated by clinic psychiatrists were significantly more likely than nonmedicated patients to be psychotic and to have been hospitalized previously, and significantly less likely to have adjustment disorder. Using standards employed by drug utilization review committees, medications were prescribed appropriately in approximately 90% of cases. Of concern, 65% of patients given antipsychotics in New York and 67% in Ohio were not psychotic; the primary target symptom in such cases was aggression. CONCLUSIONS: Prescribing practices appeared to be appropriate, although the use of antipsychotic medications in nonpsychotic children is a concern for the field of child psychiatry. The strong similarity of practices in two independent and geographically remote sites suggests the findings are generalizable to providers in other public, university affiliated settings.

A note on racial bias in the admission of children and adolescents to state mental health facilities versus correctional facilities in New York.

OBJECTIVE: In response to several studies suggesting that there is racial bias in the admission of proportionately more white children and adolescents to the child and adolescent mental health system than to the juvenile justice system, the authors tested whether white children and adolescents would be overrepresented compared with black children and adolescents in mental health facilities and underrepresented compared with black children and adolescents in juvenile correctional facilities when ethnic distribution in the general population was controlled. METHOD: Ethnicity, age, and sex of all white, black, and Hispanic 10-18-year-olds admitted in a 1-year period to facilities of the Office of Mental Health and facilities of the correctional system (the Division for Youth) of New York State were converted into rates per 100,000 population by using U.S. census data for the state. Admission rates per 100,000 population for ethnicity, age, sex, and source of referral were then compared in the two types of facilities. RESULTS: There were no meaningful differences in population-corrected admission rates among black, white, and Hispanic children and adolescents in the state mental health system. In contrast, there was a vast preponderance of black children and adolescents admitted to the state juvenile correctional system. The systems have different points of entry: 100% of the juvenile justice admissions versus 17% of the mental health admissions were referred by the courts. CONCLUSIONS: Analysis of demographic variables failed to support an allegation of racial bias in admission to the child and adolescent public mental health system in New York State.

Patient, parent, and staff attitudes toward allowing adolescent psychiatric inpatients to smoke.

A smoking attitude survey was developed and administered to adolescent patients, parents, and staff members at a psychiatric hospital for adolescents 6 months before and 6 months after the institution of a patient smoking ban. Attitudes before the ban were significantly more favorable toward allowing patient smoking than attitudes after the ban; smokers were significantly more in favor of allowing patient smoking than nonsmokers; and patients were significantly more in favor of allowing patient smoking than parents, who were significantly more in favor of allowing patient smoking than staff (overall ps less than 0.0001; post-hoc ps less than 0.05). The findings support the feasibility of implementing smoking bans in adolescent inpatient facilities.

Effects of methylphenidate on adolescents with aggressive conduct disorder and ADDH: a preliminary report.

The effect of methylphenidate on aggression in adolescents diagnosed with both aggressive conduct disorder and attention deficit disorder with hyperactivity was assessed in nine male adolescents. After three open trials, a placebo controlled double-blind design was used. During methylphenidate treatment of the six double-blind subjects, there was a significant reduction of aggressivity (p's less than 0.05), as measured by the Adolescent Antisocial Behavior Checklist. Conners Teacher Rating Scale Hyperactivity and Aggression scores were in the predicted directions, but the differences were not statistically significant.

A comparison of three nocturnal enuresis treatment methods.

To evaluate the efficacy of an operant approach that includes the bell and pad for the treatment of enuresis (Tangible Rewards with Fading), it was compared with an established operant method that includes the bell and pad (the Dry Bed method) and to a conventional Bell and Pad method. Although there were no overall statistically significant differences among the three methods, individual pairwise comparisons were of interest; the Dry Bed method had no advantage, but the Tangible Rewards with Fading method tended to have more patients reach a 14-day dryness criterion (p less than 0.10) and tended to have fewer patients relapse after treatment (p less than 0.08) than the Bell and Pad method.