Service delivery in child psychiatry: provider shortage isn't the only problem.

Although the shortage of pediatric mental health practitioners in the United States is often cited as the major stumbling block to good care, several deficiencies and problems related to service delivery may be just as great a threat to the delivery of child and adolescent psychological and psychiatric clinical care. Problems and suggestions for change related to research, training, insurance, hospitalization, practitioner collaboration and role definition are discussed.

Targeting the dopamine system in the treatment of attention-deficit/hyperactivity disorder.

Attention-deficit/hyperactivity disorder (ADHD) is a highly heritable condition that affects a significant number of children and adults worldwide. During the past 30 years, the diagnosis and treatment of ADHD has relied on clinical assessment and empirical experience with stimulant medications. More recently, advances in family genetic studies, molecular genetic studies, preclinical research, radiographic imaging techniques and neuropsychological evaluation have significantly enhanced our understanding of the neurobiology of ADHD. This review highlights the current central role of dopamine in the pathophysiology and treatment of ADHD and implications for future advances in diagnosis and treatment.

Psychopharmacologic treatment of aggressive preschoolers: a chart review.

Very young children with severe aggression are a growing focus of care in child psychiatry. Notwithstanding diagnostic uncertainties in this age group, medication, not usually considered a first-line intervention, is becoming a treatment option for a growing number of clinicians in spite of a dearth of research in this area. This chart review assessed the patient characteristics, diagnoses and treatment responses of aggressive preschoolers who were treated in a university child psychiatry outpatient clinic from 2001-2004. The most common diagnoses were Attention Deficit Hyperactivity Disorder (ADHD), Disruptive Behavior Disorder and Posttraumatic Stress Disorder (PTSD). Medication was prescribed for a majority of the children with prominent aggression; atypical antipsychotics were prescribed with the greatest frequency, followed by stimulants and then alpha agonists--treatment response ratings indicated moderate to marked improved in a majority of the preschoolers who received one or a combination of these medications. Findings support the need for controlled trials of medication in preschoolers with severe aggression.

Diagnostic profiles in outpatient child psychiatry.

Outpatient child psychiatrists appear to be treating a broadening array of complex, highly comorbid, and difficult-to-treat youths. In this study, designed to evaluate the current demographic and diagnostic profile of outpatient child psychiatric patients 1,292 outpatient records from 8 treatment settings were reviewed. Patient age, race, gender, and diagnoses were recorded and analyzed. Externalizing disorders (ADHD and/or behavior disorders) were diagnosed most frequently, followed by internalizing (depressive and anxiety) disorders. Comorbidity was evident in nearly half of all patients, regardless of age. Substance abuse was infrequently reported as a comorbid condition. Externalizing and internalizing pathology frequently co-occurred. Findings reinforce the need for clinician vigilance and thorough assessment of outpatient children and adolescents.

Oxcarbazepine in the treatment of child psychiatric disorders: a retrospective chart review.

Though not considered a first-line treatment, oxcarbazepine has become an option in the expanding effort to ameliorate severely dysregulated mood and behavioral symptoms in youth. Like most pharmaceuticals in child and adolescent psychiatry, oxcarbazepine is not U.S. Food and Drug Administration (FDA)-approved for the treatment of psychiatric disorders. A search of the world literature found a single case report pertaining to this topic. This paper is a chart review of 14 children and adolescents treated with oxcarbazepine who presented with moderate to severe problems with anger and irritability associated with a range of Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-IV) diagnoses. A majority (70%) of patients was treatment-resistant to prior psychopharmacologic efforts, and 70% were receiving combined treatment with other agents in addition to oxcarbazepine. Moderate clinical global improvement was reported in 50% of patients receiving oxcarbazepine; tolerability was good in 86%.

Current prescribing patterns in outpatient child and adolescent psychiatric practice in central New York.

OBJECTIVE: The aim of this study was to evaluate current prescribing patterns of outpatient child psychiatrists in central New York. METHODS: Data were drawn from all active files of 1- to 18-year-olds (n = 1292) at eight outpatient treatment locations in central New York on one day in 2002. Age, race, gender, diagnoses, current medications, and doses were recorded. Data was tabulated and analyzed to discern prescribing frequencies and patterns. RESULTS: 74% (956 of 1292) of all patients received psychotropic medication, and 50% of these patients (478 of 956) received two or more medications. The most commonly prescribed medications were stimulants, antidepressants, antipsychotics, alpha-agonists, and "mood stabilizer" anticonvulsants. The most frequent diagnoses were attention-deficit/hyperactivity disorder, other disruptive behavior disorders, anxiety disorders, and depressive disorders. Of those youths who received an antipsychotic medication, 77% did not have a diagnosis of a psychotic disorder. CONCLUSIONS: Psychotropic prescribing frequency in outpatient child psychiatry continues to increase, with a substantial majority of youth in psychiatric treatment receiving medication. Stimulants, antidepressants, and antipsychotics have led the way, as in prior studies. Co-prescribing represents a substantial, and growing, proportion of prescribing practice. Antipsychotics are frequently prescribed for nonpsychotic conditions.

Intramuscular ziprasidone in youth: a retrospective chart review.

OBJECTIVE: The aim of this study was to assess the tolerability and effectiveness of intramuscular ziprasidone in inpatient children and adolescents. METHOD: A retrospective chart review was conducted of child and adolescent inpatients at a private psychiatric hospital in central New York between January 1, 2003 and August 30, 2003. Subjects who had received intramuscular ziprasidone were identified, and their age, gender, and dosage were recorded. Nursing-shift notes were reviewed to ascertain the need for repeat injection and for adverse reactions. RESULTS: Forty-nine youths received intramuscular ziprasidone; 43 injections were 20 mg and 6 injections were 10 mg. Readministration within 4 hours was required in only 1 subject. No adverse events were recorded. CONCLUSION: Intramuscular ziprasidone was well tolerated and effective for acutely agitated and aggressive inpatient youth.

Aripiprazole in an adult with Asperger disorder.

OBJECTIVE: To report a case of aripiprazole-responsive adult Asperger disorder. CASE SUMMARY: A 34-year-old white man with lifelong, disabling Asperger disorder and a 20-year history of failed psychotherapeutic and pharmacologic interventions was prescribed aripiprazole, with dramatic symptomatic improvement. DISCUSSION: Multiple prior pharmacologic efforts over several years aimed predominantly at altering serotonin and dopamine neurotransmission resulted in treatment failure due to intolerable adverse effects, exacerbation of underlying symptoms, or nonresponse. Aripiprazole, with a complex profile of neurotransmitter affinities, has produced significant core symptom changes. Improved sociability; increased self-awareness; reduced rigidity, anxiety, and irritability; and reduced preoccupation with circumscribed esoteric interests are among the effects noted. CONCLUSIONS: Previously intractable Asperger disorder symptoms in a 34-year-old man were ameliorated with aripiprazole.