Depression in Children and Adolescents Involved in the Child Welfare System.

Child maltreatment presents a significant public health challenge and is strongly associated with development of depression during childhood and adolescence. Not all abused or neglected children are in the child welfare system, but most children in the foster care system have a history of maltreatment. Involvement with the child welfare system presents an additional risk for psychopathology. The role of child maltreatment and child welfare involvement in development of depression in children and adolescents is reviewed and effective treatments are discussed. Clinicians working with foster children must collaborate with care providers and other stakeholders to enhance the child's placement permanence.

Child and adolescent psychiatry leadership in public mental health, child welfare, and developmental disabilities agencies.

Child and adolescent psychiatrists are in a unique position to provide administrative and clinical leadership to public agencies. In mental health, services for children and adolescents in early childhood, school, child welfare, and juvenile justice settings, transition-aged youth programs, workforce development, family and youth leadership programs, and use of Medicaid waivers for home- and community-based service system development are described. In child welfare, collaboration between an academic child psychiatry department and a state child welfare department is described. In developmental disabilities, the role of the child and adolescent psychiatrist administrator is described providing administrative leadership, clinical consultation, quality review, and oversight of health and behavioral health plans for persons with developmental disabilities.

Psychotropic medication management for youth in state care: consent, oversight, and policy considerations.

The use of psychotropic medications in youth with emotional disturbances in state custody is increasing and presents unique challenges concerning consent and oversight. We examine various means that state child welfare agencies use to provide consent for and oversight of psychotropic medications for children in state custody and describe benefits of a consent process that provides for expert consultation to the child welfare agency and prescribing clinicians, case-specific and systemic oversight of psychotropic medication use, and education for stakeholders.

A one-year open-label trial of risperidone augmentation in lithium nonresponder youth with preschool-onset bipolar disorder.

OBJECTIVE: The aim of this study was to assess the safety and efficacy of risperidone augmentation of lithium in preschool-onset bipolar disorder (BD) among youth who insufficiently respond to lithium monotherapy. METHOD: Thirty-eight subjects between the ages of 4 and 17 years (mean age = 11.37 +/- 3.8 years) with onset of BD in preschool years (manic or mixed episode) entered this 12-month trial. All subjects received lithium monotherapy. Patients who failed to adequately respond to lithium monotherapy after 8 weeks and those who relapsed after an initial response were given risperidone augmentation for up to 11 months. The Young Mania Rating Scale (YMRS) was the primary outcome measure. Response was defined as a > or =50% decrease from baseline. Additional data were collected on diagnostic comorbidity, family history, number of hospitalizations, perinatal risk factors, history of physical or sexual abuse, Child Depression Rating Scale-Revised (CDRS-R), Clinical Global Impression (CGI) scale for BD (CGI-BP), Children's Global Assessment Scale (C-GAS), and adverse medication effects. RESULTS: Of the 38 subjects treated with lithium monotherapy, 17 responded, whereas 21 required augmentation with risperidone. Response rate in the youths treated with lithium + risperidone was 85.7% (n = 18/21). Significant predictors of inadequate response to lithium monotherapy requiring augmentation were: (1) attention-deficit/hyperactivity disorder (ADHD), (2) severity at baseline, (3) history of sexual or physical abuse, and (4) preschool age. Combination treatment of lithium and risperidone was found to be safe and well tolerated. CONCLUSIONS: A substantial proportion of youth with a history of preschool-onset BD treated with lithium were either nonresponders or partial responders. Subsequent augmentation of lithium with risperidone in these cases was well tolerated and efficacious. Potential predictors of lithium nonresponse identified in this study may guide the choice of medications earlier in the treatment process.

Pediatric bipolar disorder: a review of the past 10 years.

OBJECTIVE: To review the literature of the past decade covering the epidemiology, clinical characteristics, assessment, longitudinal course, biological and psychosocial correlates, and treatment and prevention of pediatric bipolar disorder (BD). METHOD: A computerized search for articles published during the past 10 years was made and selected studies are presented. RESULTS: Pediatric BD is increasingly recognized, and there are several prevailing views on core features of this disorder. The incidence and prevalence of the disorder and the associated comorbidities vary according to study setting and criteria used. This disorder is highly recurrent and accompanied by substantial psychiatric and psychosocial morbidity. Familial studies, including "top down" (offspring of parents with BD) and "bottom up" (relatives of youths with BD) studies indicate that pediatric BD is aggregated in families with adult or later-onset BD and suggest the existence of genetic predisposition. Greater understanding of the risk factors for early onset BD and recognition of the phenomenology of prodromal symptoms offers hope for early identification and prevention. Neuroimaging studies indicate frontotemporal and frontostriatal pathology, but none of these findings seems to be disorder specific. Combination pharmacotherapies appear promising, and the field awaits further short- and long-term randomized, placebo-controlled trials. Preliminary studies of various psychotherapies, including psychoeducation strategies tailored specifically for BD in youths, look encouraging. CONCLUSIONS: Considerable advances have been made in our knowledge of pediatric BD; however, differing viewpoints on the clinical presentation of BD in children are the rule. Phenomenological and longitudinal studies and biological validation using genetic, neurochemical, neurophysiological, and neuroimaging methods may strengthen our understanding of the phenocopy. Randomized, controlled treatment studies for the acute and maintenance treatment of BD disorder are warranted.

Divalproex sodium for pediatric mixed mania: a 6-month prospective trial.

OBJECTIVE: This prospective 6-month open trial examined the effectiveness and safety of divalproex sodium (DVPX) in pediatric mixed mania. METHOD: Thirty-four subjects with a mean age of 12.3 (SD = 3.7) years, DSM-IV diagnosis of a current mixed episode and a baseline Young Mania Rating Scale (YMRS) score >20 were treated with DVPX monotherapy. The primary outcome measures were the YMRS and the Child Depression Rating Scale-Revised. Secondary measures were the Clinical Global Impression Scale for Bipolar Disorder (CGI-BP) and the Children's Global Assessment of Functioning Scale (C-GAS). Measures of safety and tolerability were also administered. RESULTS: Effect size (Cohen's d) based on change scores from baseline was 2.9 for the YMRS and 1.23 for the CDRS-R. Response rate (> or =50% change from baseline YMRS score and < or =40 score on CDRS-R at the end of study) was 73.5%. The remission rate (> or =50% change from baseline on YMRS, < or =40 on CDRS-R, CGI-BP-Improvement subscale of < or =2, and > or =51 CGAS score) was 52.9%. Significant improvements (p < 0.001) from baseline were seen for mean scores on all outcome measures (i.e., YMRS, CGI-BP, CDRS-R, and C-GAS). DVPX was safe and well tolerated with no serious adverse events during the 6-month trial. CONCLUSION: This study provides evidence for the effectiveness and safety of DVPX in the treatment of pediatric mixed mania over a 6-month period. Placebo-controlled, randomized trials involving larger samples will ultimately shed light on the efficacy of this agent.

Open-label prospective trial of risperidone in combination with lithium or divalproex sodium in pediatric mania.

OBJECTIVE: This prospective 6-month open trial examined the safety and efficacy of two combination therapies for manic or mixed episodes of pediatric bipolar disorder: (1) divalproex sodium plus risperidone (DVPX+Risp), or (2) lithium plus risperidone (Li+Risp). METHODS: Thirty-seven (37) subjects aged 5 and 18 (age=12.1+/-3.5 years) with DSM IV current mixed or manic episode and Young Mania Rating Scale (YMRS) score >20 were sequentially assigned to either DVPX+Risp or Li+Risp in a 6-month, prospective open-label trial. Outcome measures included the YMRS, Clinical Global Impression Scale for Bipolar Disorder (CGI-BP), Child Depression Rating Scale-Revised (CDRS-R) as well as measures of safety and tolerability. RESULTS: Effect sizes (Cohen's d) based on change of YMRS scores from baseline were 4.36 for DVPX+Risp and 2.82 for Li+Risp. Response rates (>or=50% change from baseline YMRS score at the end of study) were 80% for DVPX+Risp and 82.4% for Li+Risp. Both combination treatments were well tolerated. Significant improvements (p<0.001) from baseline were seen for mean scores on all efficacy measures, i.e., YMRS, CGI-BP, and CDRS-R. There were no significant group differences in safety or tolerability, and no serious adverse events during the 6-month trial. CONCLUSION: Both DVPX+Risp and Li+Risp show strong effects coupled with safety and tolerability in treating children and adolescents with manic or mixed episodes associated with type I bipolar disorder.

A pharmacotherapy algorithm for stabilization and maintenance of pediatric bipolar disorder.

OBJECTIVE: To assess the feasibility and effectiveness of an evidence-based pharmacotherapy algorithm in the treatment of pediatric bipolar disorder. METHOD: The study reports the results of a study of 64 bipolar type I subjects who were treated according to an algorithm developed in our specialty clinic. All subjects had been diagnosed using the Washington University in St. Louis Schedule for Affective Disorders and Schizophrenia. Subjects scored an average of 28 (+/- 4) on the baseline Young Mania Rating Scale. All subjects were assessed over an 18-month period. In addition, we were able to match 17 of the 64 subjects in the algorithm sample for gender, age, ethnicity, socioeconomic status, and diagnosis with an equal number of subjects in a psychopharmacology clinic who received treatment as usual. RESULTS: Prescribing clinicians were able to implement primary and secondary strategies, including detailed tactics of medication choices in the algorithm group. Growth curve analysis of the total algorithm group showed strong and significant improvement in symptoms. Analyses of the matched groups also showed strong effects for the treatment algorithm over treatment as usual. Treatment adherence and family satisfaction were higher in the algorithm group. CONCLUSION: An evidence-based, problem-solving pharmacotherapy algorithm is feasible and may be associated with better outcomes in the treatment of pediatric bipolar disorder. Randomized trials will be necessary to gather additional support for the algorithm's effectiveness.