Sudden death related to selected tricyclic antidepressants in children: epidemiology, mechanisms and clinical implications.

The association between tricyclic antidepressant (TCA) use in children and increased risk of sudden death is unclear, but still possible. There are suitable alternatives to TCAs for all of the indications in which they have shown efficacy. A prudent practice model for the utilisation of TCAs has been developed. This includes initial utilisation of alternative agents, with TCAs as secondary or tertiary choices; informed consent from patient and family, including mention of the possible relationship of TCA with sudden death; vigilance of the emerging literature; and finally, systematic monitoring of patients, including electrocardiograms, drug serum concentrations and vital signs. This protocol needs to be validated with regard to utility and the degree of assistance it provides in the management of children treated with TCAs.

Emergence of tics in children with attention deficit hyperactivity disorder treated with stimulant medications.

The emergence of tics in children treated with stimulant medication for attention deficit hyperactivity disorder (ADHD) was investigated. A retrospective chart review of the medical records of 555 subjects was performed to examine the emergence of tics in relation to treatment with a stimulant medication, dosage, duration of treatment, and age of subjects. A total of 7.8% of the subjects treated with stimulants developed tics: 8.3% of subjects treated with methylphenidate, 6.3% with dextroamphetamine, and 7.7% with pemoline. The subjects who developed tics were significantly younger than those who did not. Subjects treated with higher doses of stimulant medication were not more likely to develop tics. While the emergence of tics was common, these subjects may have developed tics irrespective of stimulant medication. Controversy remains as to the long-term risk of tics in relation to stimulant medication and to appropriate practice should tics emerge during the course of stimulant medication treatment.

Sudden death of a child treated with imipramine. Case study.

Since 1990, there have been seven reported cases of sudden death in children treated with tricyclic antidepressants. This case study describes the sudden death of an additional child (8 years 9 months old, 29 kg in weight) treated with a tricyclic antidepressant, imipramine (100 mg orally, twice daily), and dextroamphetamine (10 mg orally every morning). Prior to death, there were signs of possible cardiovascular abnormalities after treatment was begun with imipramine. The report adds to the concern over the use of tricyclics in children.

Prediction of stimulant response in children with attention-deficit/hyperactivity disorder.

Discrimination of stimulant-responding and nonresponding groups of children with attention-deficit/hyperactivity disorder (ADHD) on the basis of demographic, neurophysiologic, or behavioral variables would be beneficial for clinical and theoretical reasons. Previous researchers have identified many predictor variables, but relationships between predictor and criterion variables generally have been subtle. In addition, few investigations have considered the relative predictive power of the variables. The present study evaluated the multivariate relationship between several predictor variables and response to medication in 336 children with ADHD. Neurologic status, inattention, and overactivity were found to be most likely to predict good response to psychostimulants, whether rated by parents or teachers. Although a number of variables predicted a positive psychostimulant response, the strength of the predictive associations suggests only minimal clinical usefulness.

Case study: two additional sudden deaths with tricyclic antidepressants.

Since 1990, there have been five reported cases of sudden death in children treated with desipramine. This case study describes the sudden deaths of two additional children treated with tricyclic antidepressants, one with desipramine, 3.3 mg/kg per day, the other with imipramine, 6 mg/kg per day and thioridazine, 1 mg/kg per day. The reports add to concerns about the use of tricyclics in children.

A survey of child and adolescent psychiatry residents : demographic characteristics, program selection factors, training satisfaction, and career choice.

This study attempted to discover how child and adolescent psychiatry residents chose their training programs, what they intended to do with their careers, and how they perceived their educational experiences. The survey was distributed to all psychiatry residents in the United States through their training directors in 1990. The authors received 310 responses. Significant differences were noted between male and female residents. Most residents expressed an intention to go into private practice after training. There were significant differences in residents interested in private practice vs. academic careers. The residents had applied to comparatively few programs and made training decisions early. The study generated objective information that may yield more specific recruitment strategies for child and adolescent psychiatry.

Pediatric cardiovascular effects of imipramine and desipramine.

Electrocardiograms were evaluated in 39 children and adolescents before and after the clinical use of imipramine and desipramine. The average increase in PR interval was 0.01 seconds. The PR interval increased by 0.02 seconds in 11 subjects, and a new first-degree atrioventricular block developed in two subjects. These changes were not related to the choice between imipramine and desipramine, the dose, or the method of administration. An increase in PR interval by 0.02 seconds or more did correlate with having an abnormality disclosed on a pretreatment electrocardiogram. The average increase in PR interval was 0.007 seconds for subjects with normal baseline electrocardiograms and 0.019 seconds for subjects with conduction and nonconduction abnormalities disclosed in baseline tracings. None of the electrocardiogram changes resulted in adverse clinical consequences.

Effects of methylphenidate on early adolescent growth.

Thirty-one hyperactive adolescents treated with methylphenidate for at least 6 months demonstrated no significant deviation from expected height and weight growth velocities. In contrast to findings in prepubertal children, these results suggest that early adolescent growth is insensitive to methylphenidate.

A two-year follow-up of autistic children treated with fenfluramine.

Six children with autism, who were treated with fenfluramine as part of a multi-center double-blind placebo-controlled crossover design study, were continued on an open trial of this medication. Follow-up evaluation of these children after 27 months indicated that numerous problems arose in the management of these children, most often resulting in discontinuation of the medication. Particularly noted were development of tolerance, appetite and weight problems, and requirements for other kinds of interventions including introduction of other psychotropic medications and change in custodial circumstances.

Diagnosis of attention deficit disorder with hyperactivity in Chinese boys.

Parental and teacher ratings of adjustment on the Achenbach Child Behavior Checklist and Teacher Rating Form were obtained on 39 subjects diagnosed as having attention deficit disorder with hyperactivity (ADDH), 31 subjects with ADDH plus learning disability (ADDH-LD), and 29 controls. Subjects were all males between the ages of 9 and 11 years and resided in Changsha, People's Republic of China. Significant group differences were found between the two clinical groups and the control group. Ratings by parents and teachers of the ADDH and ADDH-LD groups indicated more behavior problems and poorer social adjustment than controls. ADDH and ADDH-LD groups were not significantly different from one another except on ratings of school and learning problems.

A clinical nurse specialist's role in the comprehensive management of attention deficit disorder.

Attention deficit disorder or the hyperactivity syndrome is a common and chronic disorder of childhood, with potential ramifications in adolescence and into adult life. Treatment directed solely toward medication management has not been demonstrated to affect the outcome of this disorder significantly, and it is clear that comprehensive treatment is in order for these children. The role of a clinical nurse specialist with skills and abilities complementary to that of the child psychiatrist or pediatrician who can provide many of the ancillary and direct services needed by these patients is described.

Cognitive and psychiatric variability in three brothers with fragile X syndrome.

Three brothers were determined to have the fragile X syndrome. While sharing physical characteristics, their developmental and behavioral characteristics were diverse, as was the severity of the disorder. Each brother had evidence of developmental problems but demonstrated heterogeneity of presentation in the same sibship.

Atypical stimulant responder.

A six-year-old girl presented with severe emotional disturbance. The symptoms were not consistent with attention deficit disorder. The child did not manifest difficulties with attention span or distractibility. A double-blind active drug/placebo study with magnesium pemoline confirmed a beneficial pharmacologic response to the medication. The family was amenable to psychotherapy following the institution of medication.

Effects of methylphenidate on reading in children with attention deficit disorder.

Effects of methylphenidate on measures related to reading were studied in a group of nine boys who had attention deficit disorder with hyperactivity; a double-blind crossover design using active drug and placebo was used. Administration of methylphenidate improved subjects' performance on language processing tests but not their performance on oral reading measures. The findings provide evidence in support of a two-factor theory of attention deficit disorder.

Attention deficit disorder (the hyperactivity syndrome): a review of selected issues.

Attention deficit disorder, or the hyperactivity syndrome, is a common chronic disorder of childhood. Although much is known about this disorder, many questions remain unanswered. Selected issues regarding this common disorder are reviewed.

Emotional, behavioral, and cognitive status of children with cerebral gigantism.

Eleven children with cerebral gigantism or Sotos' syndrome were assessed regarding their cognitive, emotional, and behavioral status. The children demonstrated high rates of emotional and behavioral disorders, but no specific pattern or personality style was detected. On the cognitive assessments, all of the children presented with cognitive impairment or mental retardation, the range of which was variable. As with other syndromes associated with developmental delay, there was a wide range of expression of problems.

Schizophreniform psychoses in mentally retarded adolescent girls following sexual assault.

Three mildly retarded adolescent girls developed schizophreniform psychoses following sexual assault. The assault was not identified until the psychoses had cleared. The vulnerability of this population to sexual assault and psychosis is discussed.