Treatment adherence among Latina female adolescent suicide attempters.

Clinicians must identify factors among suicide-attempting adolescents and their families that increase treatment adherence. Researchers assessed a consecutive series of 140 disenfranchised Latina adolescents (ages 12-18 years) and their mothers presenting at a large urban emergency room after a suicide attempt by the adolescent. Adherence was examined as it related to service delivery, individual background characteristics, and psychosocial factors (current symptomatology, treatment attitudes). Each factor was found to predict adolescent treatment adherence. Adolescents receiving a specialized emergency room program, those with a diagnosis of disruptive behavior disorder, and those from single-parent households attended significantly more therapy sessions compared to their suicide-attempting peers receiving standard emergency room care. Adolescents with a diagnosis of anxiety disorders and those whose mothers reported more psychopathology and perceived more cohesive family relationships tended to attend significantly fewer treatment sessions. The implications for the delivery of emergency room interventions are discussed.

Microanalysis of adolescent suicide attempters and ideators during the acute suicidal episode.

OBJECTIVE: To compare psychological and event-related contingencies that characterize and differentiate adolescent suicidal ideation and attempts. METHOD: Thirty-five ideators and 32 attempters (aged 12 to 17 years) consecutively referred to the suicide disorders clinic were evaluated with a semistructured interview about current and past emotional, cognitive, and behavioral states. RESULTS: Before the precipitant stressor (baseline), attempters reported significantly more hopelessness than ideators (odds ratio [OR] = 4.2, p < .05). During the suicidal episode, attempters, relative to ideators, spent more time ideating (OR = 4.3, p < .05), were more likely to isolate themselves (OR = 5.8, p < .01), and were less likely to tell anyone what they were thinking (OR = 4.5, p < .05). In contrast, ideators reported significantly more residual anger after the episode than did attempters (OR = 4.0, p < .05). All the episodes of ideation and attempts were preceded by a stress event. No differences were found between the groups on Beck Depression inventory scores. CONCLUSIONS: Preexisting hopelessness, a tendency toward isolation, not talking about ideation, and longer length of time ideating during suicidal episodes discriminated suicide attempters from suicide ideators. Knowledge of these factors may be helpful in preventive and treatment efforts with suicidal adolescents.

Abnormality of EEG alpha asymmetry in female adolescent suicide attempters.

Abnormal electroencephalographic (EEG) activity has been associated with various psychiatric disorders and behaviors, including depression, suicide, and aggression. We examined quantitative resting EEG in Hispanic female adolescent suicide attempters and matched normal controls. Computerized EEG measures were recorded at 11 scalp sites during eyes open and eyes closed periods from 16 suicide attempters and 22 normal controls. Suicide attempters differed from normal controls in alpha asymmetry. Normal adolescents had greater alpha (less activation) over right than left hemisphere, whereas suicidal adolescents had a nonsignificant asymmetry in the opposite direction. Nondepressed attempters were distinguished from depressed attempters in that they accounted for the preponderance of abnormal asymmetry, particularly in posterior regions. Alpha asymmetry over posterior regions was related to ratings of suicidal intent, but not depression severity. The alpha asymmetry in suicidal adolescents resembled that seen for depressed adults in its abnormal direction, but not in its regional distribution. Findings for suicidal adolescents are discussed in terms of a hypothesis of reduced left posterior activation, which is not related to depression but to suicidal or aggressive behavior.

Enhancing treatment adherence with a specialized emergency room program for adolescent suicide attempters.

OBJECTIVE: The evaluation of outpatient treatment adherence among 140 Latina adolescent suicide attempters and their families. METHOD: Sequentially, 75 attempters received standard emergency room care and 65 attempters received a specialized emergency room program including (1) training workshops for emergency room staff, (2) a videotape aimed at modifying families' treatment expectations, and (3) an on-call family therapist. RESULTS: Attempters receiving the specialized program were more likely to attend one treatment session (95.4% versus 82.7%) and were somewhat more likely to attend more sessions (5.7 versus 4.7) than those receiving standard emergency room care; however, their mothers were less likely to complete treatment. In addition, participants receiving the specialized program reported reduced psychiatric symptoms, and mothers reported more positive attitudes toward treatment and perceptions of family interactions. CONCLUSIONS: Adherence was significantly improved by receiving the specialized care program in the emergency room. Adherence was also associated with increased suicidal ideation, more cohesive family relations, and lower self-esteem at baseline.

Demographic predictors of treatment attendance among adolescent suicide attempters.

The relationship between age and gender and treatment attendance was prospectively examined among a consecutive series of 143 adolescent emergency room attendees referred for outpatient therapy after a suicide attempt. Consistent with previous reports, nonadherence was high. Over 40% of patients had their cases terminated because of nonattendance; on average, however, patients received almost 6 sessions of treatment and 91% attended at least 1 therapy session. Adolescents terminated from treatment for nonadherence were significantly older than those completing treatment. Younger male patients were scheduled for significantly more therapy sessions than older male patients and kept significantly more scheduled sessions than did older male and female patients. Vigorous case-tracking procedures may have a significant impact on treatment attendance. Nevertheless, therapists must design strategies to increase treatment adherence among older adolescent, especially male, patients.

Brief cognitive-behavioral treatment for adolescent suicide attempters and their families.

OBJECTIVE: This article describes a brief, standardized, cognitive-behavioral treatment program for adolescent suicide attempters and their families. METHOD: Successful Negotiation Acting Positively (SNAP) treatment consists of a series of structured activities that create a positive family atmosphere, teach problem-solving skills, shift the family's understanding of their problems to troublesome situations rather than difficult individuals, and build confidence in the treatment professional, thereby reducing conditions associated with future attempts. RESULTS: SNAP treatment has been systematically administered to more than 100 suicidal adolescents and their families as part of an ongoing treatment study. Although these results are not yet available, our initial experience suggests that SNAP treatment can be delivered in a reliable fashion and is well accepted by both patients and therapists. CONCLUSIONS: Although suicidality in youth constitutes a major public health problem, few therapeutic interventions have been developed specifically for suicidal adolescents. SNAP treatment addresses a number of issues critical to successful interventions with this population, including their historically poor treatment compliance, the need for family involvement in treatment, and an emphasis on coping and problem-solving strategies. Moreover, the brief, structured format of SNAP treatment is consistent with the growing trend toward standardized, empirically tested, and cost-efficient interventions.

Clonazepam in childhood anxiety disorders.

OBJECTIVE: There is evidence for the efficacy and safety of clonazepam (CZP) in adult anxiety disorders, but no formal studies to substantiate clinical reports of similar benefit in children with anxiety disorders. METHOD: In this double-blind pilot study, 15 children, aged 7 to 13 years, entered a randomly assigned, double-blind crossover trial of 4 weeks of CZP (up to 2 mg/day) and 4 weeks of placebo. RESULTS: Twelve children completed the trial. All but 1 had a diagnosis of separation anxiety disorder, and all but 2 had comorbid diagnoses. Nine children appeared to have moderate to significant clinical improvement, but statistical comparisons on several ratings failed to confirm a trend in favor of CZP. Side effects of drowsiness, irritability, and/or oppositional behavior were notable in 10 children in the CZP phase compared with 5 in the placebo phase. CONCLUSIONS: Clonazepam was believed to have clinical benefit for some children, but this was not confirmed statistically in this small sample. Problematic side effects of drowsiness and disinhibition were common and possibly were due to rapid titration.

Psychopharmacologic treatment of child and adolescent obsessive compulsive disorder.

Recent evidence now suggests that OCD is much more common in young people than previously thought, affecting up to 200,000 children and adolescents in the United States alone. Unlike many childhood disorders, OCD appears remarkably similar for children and adults in terms of both clinical presentations and treatment response. The treatments of choice for OCD are antidepressants with potent serotonergic reuptake blocking effects such as fluoxetine and clomipramine. Both medications appear to be equally effective in terms of symptom remission, with different investigators reporting response rates in the range of 50% to 75%. Recent evidence suggests, however, that fluoxetine may be tolerated more easily than clomipramine and may be associated with less relapse upon discontinuation. Behavior therapy, either alone or in combination with medication, has been shown to be an effective alternative treatment. In spite of the increasing recognition of the disorder in both adults and children, only a handful of treatment outcome studies of child and adolescent OCD have been conducted and much work remains to be done in this area.

High anxiety in children.

Although reliable biological markers of dysfunctional childhood anxiety disorders are lacking, such disorders can be recognized by their symptoms. In separation anxiety and avoidance disorders, anxiety is limited to certain settings; in overanxious disorder, anxiety is generalized. Treatment for childhood anxiety disorders has included behavioral and pharmacologic intervention alone or in combination, but evidence of the efficacy of medical treatment is sparse. Some antidepressants and benzodiazepines have undergone limited studies. Clonazepam has been chosen for further study because in adults it reduced panic attacks and produced few serious side effects. In extensive studies of clonazepam for childhood seizure disorders, side effects were reported, but later reports indicate that many side effects were due to rapid induction and large doses. Transient drowsiness, lethargy, irritability, or excitability have been reported in various epilepsy studies. Clonazepam's minimal potential for drug interactions is another feature recommending it for extended trials in childhood anxiety disorders, and such a double-blind crossover study is underway.

The effects of prolonged stimulus repetition with repeated switching of target status on the orienting response in schizophrenia and depression.

Schizophrenic patients are frequently orienting nonresponders to innocuous stimuli, become responsive to significant target signals, and become hyporesponsive again on prolonged repetition. We wish to a) determine whether schizophrenic patients can display orienting response (OR) flexibility, responding to newly designated targets and ceasing to respond to newly designated nontargets; b) determine whether renewed hyporesponding can be averted with reminders of target relevance and repeated introduction of new targets; and c) compare schizophrenics with depressives and normal controls. Fifty schizophrenics (14 drug free), 50 depressives (20 drug free), and 50 normal controls receive four trial blocks involving the same sequence of 16 1000- or 2000-Hz tones delivered to either the right or left ear. A subsample of each group (N = 14) receives all blocks as a simple habituation series; others (N = 36) have to press a pedal for designated target signals (left ear or right ear, 1000 Hz or 2000 Hz), ignoring all nontarget tones. On each trial block, a new target signal is defined, and previous targets are discarded. Skin conductance and finger pulse amplitude analyses are presented. Both patient groups show enhanced ORs to newly relevant targets and ceased ORs to newly irrelevant former targets as well as normals. Both show OR decline with target repetition despite reminders and new targets.