The Many Faces (and Names) of Mood Dysregulation.

Explosive outbursts in children and adolescents have been long identified by clinicians and have been described using many different conceptualizations and terms. The topography of explosive outbursts is complex, heterogeneous, and includes the interactions of different emotional and behavioral constructs. Included here are pre-existing central nervous system vulnerabilities including psychiatric and neurologic diagnoses, various contributing emotions that generally carry a negative valence, and aggressive behaviors that are usually overt and reactive. Emotional impulsivity and deficient emotional self-regulatory mechanisms may contribute to episode severity and duration.

Does Anxiety Modify the Risk for, or Severity of, Conduct Problems Among Children With Co-Occurring ADHD: Categorical and Dimensional and Analyses.

OBJECTIVE: The goal was to examine whether anxiety modifies the risk for, or severity of, conduct problems in children with ADHD. METHOD: Assessment included both categorical and dimensional measures of ADHD, anxiety, and conduct problems. Analyses compared conduct problems between children with ADHD features alone versus children with co-occurring ADHD and anxiety features. RESULTS: When assessed by dimensional rating scales, results showed that compared with children with ADHD alone, those children with ADHD co-occurring with anxiety are at risk for more intense conduct problems. When assessment included a Diagnostic and Statistical Manual of Mental Disorders (4th ed.; DSM-IV) diagnosis via the Schedule for Affective Disorders and Schizophrenia for School Age Children-Epidemiologic Version (K-SADS), results showed that compared with children with ADHD alone, those children with ADHD co-occurring with anxiety neither had more intense conduct problems nor were they more likely to be diagnosed with oppositional defiant disorder or conduct disorder. CONCLUSION: Different methodological measures of ADHD, anxiety, and conduct problem features influenced the outcome of the analyses.

Atypical and Severe Nonsuicidal Self-Injury as an Indicator of Severe Psychopathology: Findings From a Sample of High-Risk Community Mental Health Clients.

This study examined whether atypical/severe nonsuicidal self-injury (NSSI; e.g., foreign body ingestion, cutting necessitating sutures) serves as a marker of severe psychopathology among 467 adult community mental health clients (n = 33 with an atypical/severe NSSI history). Information regarding psychiatric risk indicators was extracted from participants' psychiatric records. Generalized linear models with negative binomial distribution and log link function, as well as chi-square tests, were used to address study aims. Clients with a lifetime atypical/severe NSSI history met criteria for a significantly greater number of psychiatric risk indicators than clients with a lifetime history of common NSSI only; however, these clients were not significantly more likely to report recent suicidal actions. Individuals with an atypical/severe NSSI history may demonstrate more severe psychopathology than those with a history of common NSSI only. Thus, it may be clinically useful to consider individuals with an atypical/severe NSSI history as a high-risk subgroup.

The Development of Comorbid Conduct Problems in Children With ADHD: An Example of an Integrative Developmental Psychopathology Perspective.

OBJECTIVE: We describe interactions among factors that contribute to the development of conduct problems among children with ADHD. METHOD: An integrative developmental psychopathology analysis combines various approaches and posits one model of how diverse risk factors operate together to contribute to the development of conduct problems among children with ADHD. RESULTS: Substantial genetic risk increases covariation between ADHD and conduct problems. Candidate genes are associated with CNS monoaminergic neurotransmission. Subsequent neurodevelopmental impairment interferes with executive function, with impaired verbal working memory playing an important role. Parent/child bi-directional influences exacerbate the risk for conduct problems when ADHD symptoms increase the likelihood of a coercive parenting style. Parent stress in reaction to child comorbid ADHD and conduct problems, and parent attribution for the child's conduct problem behavior, add to the potential for coercion and reduce constructive parent-child interaction that might otherwise enhance the development of verbal working memory. CONCLUSION: In an integrated manner, these variables increase the risk that a child with ADHD will subsequently develop conduct problems.

Mental health issues among college students: who gets referred for psychopharmacology evaluation?

OBJECTIVE: To describe diagnostic and psychotropic medication prescription characteristics among college students referred by college counseling centers for psychopharmacologic evaluation. PARTICIPANTS: Participants were 540 college students referred by 6 college counseling centers in Massachusetts between November 2005 and May 2011. METHODS: Students completed self-report measures of depression, anxiety, suicidal ideation and attempts, and substance use. Information regarding DSM-IV (Diagnostic and Statistical Manual of Mental Disorders, 4th edition) diagnosis, previous history of medication prescription, and current psychotropic medication(s) prescribed by the consulting psychiatrist was obtained from medical records. RESULTS: Depression, anxiety, and attention-deficit/hyperactivity disorder (ADHD) were the most common psychiatric problems identified in students. Half of these students had been prescribed mediation prior to evaluation. Antidepressant medication was the most frequently prescribed medication. A large proportion of students reported previous thoughts of suicide, and 12% had made at least 1 suicide attempt. CONCLUSIONS: Depression, anxiety, and ADHD are common among students referred by college counseling centers for medication evaluation and treatment.

Population-based initiatives in college mental health: students helping students to overcome obstacles.

College students' need for mental health care has increased dramatically, leaving campus counseling and mental health centers struggling to meet the demand. This has led to the investigation and development of extra-center, population-based interventions. Student-to-student support programs are but one example. Students themselves are a plentiful, often-untapped resource that extends the reach of mental health services on campus. Student-to-student programs capitalize on students' natural inclination to assist their peers. A brief review of the prevalence and effects of mental disorders in the college population is provided, followed by a broad overview of the range of peer-to-peer programs that can be available on college campuses. Two innovative programs are highlighted: (1) a hospital- and community-based program, the College Mental Health Program (CMHP) at McLean Hospital, and 2) the Student Support Network (SSN) at Worcester Polytechnic Institute. The subsequent section reviews the literature on peer-to-peer programs for students with serious and persistent mental illness for which there is a small but generally positive body of research. This lack of an empirical basis in college mental health leads the authors to argue for development of broad practice-research networks.

Characteristics of children with juvenile bipolar disorder or disruptive behavior disorders and negative mood: can they be distinguished in the clinical setting?

BACKGROUND: Because of continuing controversy over distinguishing juvenile bipolar disorder (JBD) from disruptive behavior disorders (DBDs) in the clinical setting, we investigated whether referred children with a DBD and a negative mood component could be differentiated from those diagnosed with JBD. The distinction is important because treatments differ. METHODS: In this single-site sample, 96 children with non-attention-deficit/hyperactivity DBD and depression were compared with 27 JBD children and 187 psychiatric comparison children on measures assessing behavior, functional impairment, symptom severity, psychopathology, and comorbid psychiatric diagnosis. RESULTS: Few differences were found between children with DBD and depression and those with JBD on measures of conduct problems, oppositionality, aggression, hostility, and psychopathology. More functional impairment was found in the JBD group who also had higher rates of comorbid posttraumatic stress disorder (PTSD), substance use disorders, and suicidality than the other groups. CONCLUSIONS: These results do not support the specificity of aggression as a defining criterion for JBD and clinicians assessing such patients also should consider complex DBDs with an associated depressive component in the differential diagnosis. Children with JBD must be specifically assessed for comorbid developmental trauma, substance abuse, and suicidality. The association between JBD and PTSD needs further investigation in clinical research.

Aggression, ADHD symptoms, and dysphoria in children and adolescents diagnosed with bipolar disorder and ADHD.

BACKGROUND: This study had two objectives: (1) examine characteristics of aggression in children and adolescents diagnosed with bipolar disorder and (2) determine whether the CBCL pediatric bipolar disorder profile differentiated youngsters with bipolar disorder from youngsters with ADHD. METHOD: Children and adolescents referred to a pediatric psychopharmacology clinic were systematically evaluated for psychopathology using a psychiatrist-administered diagnostic interview, parent- and teacher-report rating scales assessing the child's behavior, and child-completed self-report scales. In this sample, 27 children and adolescents were diagnosed with bipolar disorder and 249 youngsters were diagnosed with ADHD without co-occurring bipolar disorder. These two groups were compared to determine whether there were significant differences on various measures of psychopathology. RESULTS: Youngsters diagnosed with bipolar disorder were more verbally aggressive and exhibited higher levels of reactive aggression than youngsters with ADHD without co-occurring bipolar disorder. Youngsters with bipolar disorder also reported higher levels of depressive symptoms than youngsters with ADHD without bipolar disorder. The CBCL pediatric bipolar disorder profile did not accurately identify youngsters diagnosed with bipolar disorder. CONCLUSIONS: The present findings present a picture of manic youngsters as verbally aggressive and argumentative, who respond with anger when frustrated. Youngsters diagnosed with bipolar disorder and ADHD exhibited significant levels of impulsive behavior and attention problems, but youngsters with bipolar disorder also exhibited significant levels of aggressive behavior and dysphoric mood. Finally, the CBCL pediatric bipolar disorder profile did not accurately identify youngsters who were diagnosed with bipolar disorder.

ADHD with comorbid oppositional defiant disorder or conduct disorder: discrete or nondistinct disruptive behavior disorders?

OBJECTIVE: In children with ADHD who have comorbid disruptive behavior diagnoses distinctions between oppositional defiant disorder (ODD) and conduct disorder (CD) remain unclear. The authors investigate differences between ODD and CD in a large clinical sample of children with ADHD. METHOD: Consecutively referred and systematically assessed male children and adolescents with either ADHD (n = 65), ADHD with ODD (n = 85), or ADHD with CD (n = 50) were compared using structured diagnostic interviews and parent, teacher, and clinician rating scales. RESULTS: In children with ADHD, significant differences emerged between ODD and CD in the domains of delinquency, overt aggression, and ADHD symptom severity; ADHD with CD was most severe, followed by ADHD with ODD, and ADHD had the least severe symptoms. Distinctions between ADHD with CD and the other two groups were found for parenting, treatment history, and school variables. CONCLUSION: Within the limits of a cross-sectional methodology, results support clinically meaningful distinctions between ODD and CD in children with ADHD.

Separation anxiety and panic disorder in clinically referred youth.

This study examined whether youngsters with separation anxiety disorder (SAD) and panic disorder (PD) had experienced more separation-related events than youngsters with SAD (without comorbid PD). We also examined whether age of onset of SAD and comorbidity with other psychological disorders was related to the occurrence of PD. We compared youngsters who were diagnosed with SAD and PD (N=31) with youngsters who were diagnosed with SAD without comorbid PD (N=63) for the number of separation-related events, severity of psychopathology, and parent and child CBCL ratings, age of onset of SAD, and the number of comorbid diagnoses. The findings indicate that youngsters with SAD and PD had a later age of onset of SAD and more extensive psychopathology and functional impairment than youngsters with SAD (without comorbid PD). Contrary to hypothesis, there were no differences between the groups in the occurrence or number of separation-related events.

Conduct disorder subtype and comorbidity.

BACKGROUND: Conduct disorder is considered difficult to treat, but comorbid psychiatric disorders may be a basis for treating some youths with conduct disorder. We sought to identify patterns of comorbid psychiatric diagnoses and psychopathology associated with conduct disorder by reported age-of-onset. METHODS: Referred children and adolescents, aged 4-17 years old, were clinically evaluated. Ages of onset of CD symptoms (N=53) were ascertained and divided according to DSM-IV criteria as childhood onset (<10 years old) or adolescent onset (>or=10 years old). RESULTS: Childhood-onset conduct disorder was associated with higher rates of ADHD and anxiety disorders, male gender, and perceived and total hostility scores than adolescent-onset conduct disorder. Adolescent-onset was associated with higher rates of PTSD, alcohol and substance use disorders, complex comorbidity (i.e., 6+ diagnoses lifetime), and female gender. CONCLUSIONS: Understanding age-of-onset-related patterns of comorbidity may facilitate psychiatric treatment planning in children and adolescents with conduct disorder.

Panic disorder in clinically referred children and adolescents.

The present study examined the frequency and characteristics of panic disorder in children and adolescents who had been referred to a pediatric psychopharmacology clinic. Of the 280 children and adolescents evaluated in this clinic, 35 were diagnosed with panic disorder using a semi-structured clinical interview (K-SADS) and other objective measures. Approximately half of the youngsters with panic disorder also met criteria for the diagnosis of agoraphobia. There was extensive comorbidity between panic disorder and other internalizing and externalizing disorders. Parents reported clinically significant levels of child symptomatology on the CBCL. Teacher-and child-reported symptomatology on the CBCL was within the normal range. At the same time, it was notable that no child had been referred specifically for evaluation or treatment of panic disorder or agoraphobia. Implications for clinical assessment/identification and treatment are discussed.

Post-traumatic stress disorder in patients with coronary artery disease: screening and management implications.

OBJECTIVES: To review the literature on anxiety, post-traumatic stress disorder (PTSD) and depression in patients with coronary artery disease (CAD), and to present an approach to diagnosis and treatment. METHODS: MEDLINE and PsychInfo searches of English-language articles were performed. Search terms included 'anxiety', 'post-traumatic stress disorder' and 'depression', with various cardiac-related subject headings. RESULTS: Research indicates that anxiety, PTSD and depression occur frequently in patients with CAD, but these psychological problems are rarely identified or treated in the cardiology or primary care setting. CONCLUSIONS: The present review offers practical recommendations on how to detect and assess anxiety, PTSD and depression in the cardiology or primary care setting. Treatment recommendations are provided, with a focus on pharmacotherapy for anxiety and depressive disorders in patients with CAD.

Relationship of quality of life and perceived control with posttraumatic stress disorder symptoms 3 to 6 months after myocardial infarction.

PURPOSE: This study examined whether psychological variables were associated with posttraumatic stress disorder (PTSD) symptoms 3 to 6 months after myocardial infarction. METHODS: The sample included 52 patients with myocardial infarction. A structured interview was used to obtain information about PTSD symptoms, quality of life, and ratings of perceived control, danger, and predictability, as well as information about stressful events that occurred during hospitalization. RESULTS: Four patients (7.7%) met criteria for the diagnosis of PTSD. Elevated PTSD scores were associated with poorer quality of life (r = -0.32 to -0.79). Lower perceived control was associated with higher PTSD symptom scores (r = -0.30 to -0.52). Finally, PTSD scores were significantly correlated with the number of times patients were readmitted to the hospital (r = 0.35-0.57). CONCLUSIONS: Approximately 8% of patients experienced PTSD 3 to 6 months following MI. Increasing levels of PTSD symptoms were correlated with poorer quality of life. Perceived lack of control during the MI and multiple hospitalizations may be related to the severity of PTSD symptoms.

Aggressive behavior in abused children.

Our objective was to investigate the relationship between a lifetime history of traumatic stress, defined as physical and/or sexual abuse and aggression and psychosocial functioning in a sample of clinically referred and nonclinically referred children and adolescents. This is a retrospective case comparison study. Three groups of children were identified, assessed, matched for age, and partially matched for gender. Children clinically referred to residential treatment with a history of abuse (N = 29) were compared with children clinically referred to residential treatment without a history of abuse (N = 29), and a nonclinical group of children residing in the community (N = 29). Variables investigating specific types of aggression, IQ, and psychopathology were assessed across the three groups. Clinically referred children scored worse on all measures compared with nonclinical community children. Clinically referred abused children scored higher on measures of aggression and significantly higher on measures of reactive aggression and verbal aggression than clinically referred nonabused children. Clinically referred abused children had significantly lower verbal IQ scores than clinically referred nonabused children, but no difference in psychopathology. Results support the importance of assessing specific types of aggression in samples of traumatized youths. Verbal information processing may be especially vulnerable in abused children and adolescents and enhance vulnerability to aggressive responding.

Evaluating mental health outcomes in an inpatient setting: convergent and divergent validity of the OQ-45 and BASIS-32.

The evolution of managed behavioral health care has led to an increased emphasis on reliable and valid assessment of outcomes in clinical practice. The present study evaluated the convergent, divergent, and concurrent validity and sensitivity to change of two widely used measures: Behavior and Symptom Identification Scale (BASIS-32) and Outcome Questionnaire (OQ-45). Comparisons of the two measures revealed that both were sensitive to change over a relatively short inpatient stay. Both measures also showed evidence of convergent and divergent validity of specific subscales, although the total scores of each measure also were highly correlated. Evidence of concurrent validity was suggested by differences between diagnostic groups on specific subscale scores. Together with previous research, these results suggest that the BASIS-32 and OQ-45 can be useful measures for tracking patient functioning over a range of treatment contexts.