American Academy of Child & Adolescent Psychiatry (AACAP): Psychopharmacology Update Institute

The DSM-5 is expected to place obsessive-compulsive disorder and posttraumatic stress disorder into their own diagnostic categories, removing them from the family of anxiety disorders, according to Dr. Daniel S. Pine.

Setting trauma-related and obsessive-compulsive spectrum disorders off on their own makes sense because the "longitudinal outcomes, comorbidities, familial aggregations, and underlying biology" suggest the conditions are different from anxiety disorders, said Dr. Pine, chief of the section on development and affective neuroscience at the National Institute of Mental Health in Bethesda, Md.

This new approach also makes sense because the disorders that will be left in the anxiety category – generalized, social, separation, panic, and phobic anxieties – are pretty much treated the same way. "Nothing in the treatment literature suggests we should approach any of these [problems] differently from any of the others," Dr. Pine said at a psychopharmacology update sponsored by the American Academy of Child and Adolescent Psychiatry.

Overall, such problems "are incredibly common [in children]. One in three will, some time in their adolescence, have an anxiety disorder." They go away in most, but the minority in whom they persist "account for the majority of chronic mood and anxiety disorders" in adults, he said.

It’s probably the same for "substance abuse, conduct problems, personality disorders, eating disorders, mood disorders," and other problems. Children who don’t overcome those issues are the "precursors for adults who have a problem," Dr. Pine said.

"The hope of neuroscience is that it will give us better clues about" which anxious children will progress, he said. "We’re very bad at predicting that right now." Children who are worse seem to do worse over time, but beyond that, gender, age, type of anxiety disorder, and other factors do not seem to predict persistence into adulthood, he said.

As with adults, selective serotonin reuptake inhibitors (SSRIs) "are extremely good" for treating anxiety in children, and "there’s particularly good" evidence for fluvoxamine, fluoxetine, paroxetine, and sertraline. Across studies, the number needed to treat is about three, which is "about as good a treatment as we can get," he said, noting that SSRIs are "much better treatments" for anxiety than for depression (J. Am. Acad. Child Adolesc. Psychiatry 2003;42:415-23).

But because anxiety disorders are transient in most children and the effect of SSRIs on developing brains is unknown, children "deserve a trial off medication" after a year of treatment, he said.

There’s also "very good evidence" that cognitive-behavioral therapy (CBT) helps anxiety, too, though it might be a bit slower than SSRIs. Combining the two also is a possibility. In one 12-week study (N. Engl. J. Med. 2008;359:2753-66), it was clear that combination treatment was the best, Dr. Pine said.

Despite the value of treating anxiety with SSRIs, it is important to remain vigilant of the increased risk of suicidal ideations and attempts that accompany use of these medications in children and adolescents. "You really are obliged to spend a fair amount of time reviewing with parents the nature of that risk," he said.

Dr. Pine said that he had no financial disclosures.

[email protected]

The DSM-5 is expected to place obsessive-compulsive disorder and posttraumatic stress disorder into their own diagnostic categories, removing them from the family of anxiety disorders, according to Dr. Daniel S. Pine.

Setting trauma-related and obsessive-compulsive spectrum disorders off on their own makes sense because the "longitudinal outcomes, comorbidities, familial aggregations, and underlying biology" suggest the conditions are different from anxiety disorders, said Dr. Pine, chief of the section on development and affective neuroscience at the National Institute of Mental Health in Bethesda, Md.

This new approach also makes sense because the disorders that will be left in the anxiety category – generalized, social, separation, panic, and phobic anxieties – are pretty much treated the same way. "Nothing in the treatment literature suggests we should approach any of these [problems] differently from any of the others," Dr. Pine said at a psychopharmacology update sponsored by the American Academy of Child and Adolescent Psychiatry.

Overall, such problems "are incredibly common [in children]. One in three will, some time in their adolescence, have an anxiety disorder." They go away in most, but the minority in whom they persist "account for the majority of chronic mood and anxiety disorders" in adults, he said.

It’s probably the same for "substance abuse, conduct problems, personality disorders, eating disorders, mood disorders," and other problems. Children who don’t overcome those issues are the "precursors for adults who have a problem," Dr. Pine said.

"The hope of neuroscience is that it will give us better clues about" which anxious children will progress, he said. "We’re very bad at predicting that right now." Children who are worse seem to do worse over time, but beyond that, gender, age, type of anxiety disorder, and other factors do not seem to predict persistence into adulthood, he said.

As with adults, selective serotonin reuptake inhibitors (SSRIs) "are extremely good" for treating anxiety in children, and "there’s particularly good" evidence for fluvoxamine, fluoxetine, paroxetine, and sertraline. Across studies, the number needed to treat is about three, which is "about as good a treatment as we can get," he said, noting that SSRIs are "much better treatments" for anxiety than for depression (J. Am. Acad. Child Adolesc. Psychiatry 2003;42:415-23).

But because anxiety disorders are transient in most children and the effect of SSRIs on developing brains is unknown, children "deserve a trial off medication" after a year of treatment, he said.

There’s also "very good evidence" that cognitive-behavioral therapy (CBT) helps anxiety, too, though it might be a bit slower than SSRIs. Combining the two also is a possibility. In one 12-week study (N. Engl. J. Med. 2008;359:2753-66), it was clear that combination treatment was the best, Dr. Pine said.

Despite the value of treating anxiety with SSRIs, it is important to remain vigilant of the increased risk of suicidal ideations and attempts that accompany use of these medications in children and adolescents. "You really are obliged to spend a fair amount of time reviewing with parents the nature of that risk," he said.

Dr. Pine said that he had no financial disclosures.

[email protected]

The DSM-5 is expected to place obsessive-compulsive disorder and posttraumatic stress disorder into their own diagnostic categories, removing them from the family of anxiety disorders, according to Dr. Daniel S. Pine.

Setting trauma-related and obsessive-compulsive spectrum disorders off on their own makes sense because the "longitudinal outcomes, comorbidities, familial aggregations, and underlying biology" suggest the conditions are different from anxiety disorders, said Dr. Pine, chief of the section on development and affective neuroscience at the National Institute of Mental Health in Bethesda, Md.

This new approach also makes sense because the disorders that will be left in the anxiety category – generalized, social, separation, panic, and phobic anxieties – are pretty much treated the same way. "Nothing in the treatment literature suggests we should approach any of these [problems] differently from any of the others," Dr. Pine said at a psychopharmacology update sponsored by the American Academy of Child and Adolescent Psychiatry.

Overall, such problems "are incredibly common [in children]. One in three will, some time in their adolescence, have an anxiety disorder." They go away in most, but the minority in whom they persist "account for the majority of chronic mood and anxiety disorders" in adults, he said.

It’s probably the same for "substance abuse, conduct problems, personality disorders, eating disorders, mood disorders," and other problems. Children who don’t overcome those issues are the "precursors for adults who have a problem," Dr. Pine said.

"The hope of neuroscience is that it will give us better clues about" which anxious children will progress, he said. "We’re very bad at predicting that right now." Children who are worse seem to do worse over time, but beyond that, gender, age, type of anxiety disorder, and other factors do not seem to predict persistence into adulthood, he said.

As with adults, selective serotonin reuptake inhibitors (SSRIs) "are extremely good" for treating anxiety in children, and "there’s particularly good" evidence for fluvoxamine, fluoxetine, paroxetine, and sertraline. Across studies, the number needed to treat is about three, which is "about as good a treatment as we can get," he said, noting that SSRIs are "much better treatments" for anxiety than for depression (J. Am. Acad. Child Adolesc. Psychiatry 2003;42:415-23).

But because anxiety disorders are transient in most children and the effect of SSRIs on developing brains is unknown, children "deserve a trial off medication" after a year of treatment, he said.

There’s also "very good evidence" that cognitive-behavioral therapy (CBT) helps anxiety, too, though it might be a bit slower than SSRIs. Combining the two also is a possibility. In one 12-week study (N. Engl. J. Med. 2008;359:2753-66), it was clear that combination treatment was the best, Dr. Pine said.

Despite the value of treating anxiety with SSRIs, it is important to remain vigilant of the increased risk of suicidal ideations and attempts that accompany use of these medications in children and adolescents. "You really are obliged to spend a fair amount of time reviewing with parents the nature of that risk," he said.

Dr. Pine said that he had no financial disclosures.

[email protected]

WASHINGTON – The DSM-5’s inclusion of separate criteria for posttraumatic stress disorder in preschool children probably will lead to more young children getting the diagnosis, which will be a positive development because PTSD is under-recognized in this population, Dr. Michael S. Scheeringa contended.

The preschool criteria are child friendly. Intrusive recollections, for instance, don’t have to be distressing, as in the adult criteria, because sometimes such recollections do not seem to bother very young kids. "They’ll bring up their intrusive recollections to the cashier at the supermarket and seem eager to talk about them, rather than distressed," he said.

Similarly, detachment and estrangement criteria have been "reworded to say ‘socially withdrawn,’ because children can’t verbalize that they feel detached, but it can be observed that they are socially withdrawn," said Dr. Scheeringa, a pediatric PTSD researcher who also serves as an associate professor of psychiatry and neurology at Tulane University in New Orleans.

Perhaps the biggest change is that preschool children – those below the age of 7 years – will need to show just one avoidance and numbing symptom instead of the three required by the DSM-IV. Three is "too high for young children because they can’t show or express a lot of those internalized avoidance and numbing symptoms. It’s just developmentally impossible, like the sense of a foreshortened future – a child’s sense of future when they are 3 or 4 is tomorrow," he said at a psychopharmacology update sponsored by the American Academy of Child and Adolescent Psychiatry.

The increase in the number of young children likely to get the PTSD diagnosis under the new criteria is significant, because the illness historically has been underdiagnosed and missed in children, said Dr. Scheeringa, whose research contributed to the changes.

The DSM-IV requirement for irritability and anger outbursts also has been tweaked for preschoolers to include extreme temper tantrums, and the requirement for diminished interest in significant activities has been broadened to include restrictions in play and social interactions. "Young children don’t have jobs; they don’t have school; they don’t have hobbies. What they do is play and interact with other people; that’s where their interests would be diminished," he said.

"A skeptic might say, ‘Aren’t you just diagnosing mildly symptomatic kids? Aren’t you just lowering the bar?’ " but that doesn’t seem to be the case – the DSM-IV was simply missing small children with PTSD, he said.

In one of Dr. Scheeringa’s studies, DSM-IV criteria diagnosed PTSD in 13% of 284 trauma-exposed children aged 3-6 years; the DSM-5 criteria did so in about half, and those children had at least six symptoms (J. Trauma Stress 2012;25:359-67).

"Usually in treatment studies, they require five symptoms, so [these children] were really symptomatic. We’re not just diagnosing mildly symptomatic kids with" the new approach, Dr. Scheeringa said.

In general, psychotherapy – trauma-focused cognitive-behavioral therapy (CBT) in particular – is the first-line treatment for PTSD in both children and adults. "I would consider [psychiatric drugs] a distant second," he said. If needed, prazosin is likely to help with nightmares, benzodiazepines can take the edge off situational anxiety, and sleeping pills can calm fitful sleep. SSRIs might help with overall anxiety, he said.

Comorbid depression and other problems get better as PTSD resolves, "so I would suggest, based on the evidence, to focus on the PTSD first and then see what’s left over," Dr. Scheeringa said.

Attention-deficit/hyperactivity disorder (ADHD) is the exception; patients will do better in CBT if their ADHD is under control, he said.

Dr. Scheeringa said that he had no financial disclosures.

[email protected]

WASHINGTON – The DSM-5’s inclusion of separate criteria for posttraumatic stress disorder in preschool children probably will lead to more young children getting the diagnosis, which will be a positive development because PTSD is under-recognized in this population, Dr. Michael S. Scheeringa contended.

The preschool criteria are child friendly. Intrusive recollections, for instance, don’t have to be distressing, as in the adult criteria, because sometimes such recollections do not seem to bother very young kids. "They’ll bring up their intrusive recollections to the cashier at the supermarket and seem eager to talk about them, rather than distressed," he said.

Similarly, detachment and estrangement criteria have been "reworded to say ‘socially withdrawn,’ because children can’t verbalize that they feel detached, but it can be observed that they are socially withdrawn," said Dr. Scheeringa, a pediatric PTSD researcher who also serves as an associate professor of psychiatry and neurology at Tulane University in New Orleans.

Perhaps the biggest change is that preschool children – those below the age of 7 years – will need to show just one avoidance and numbing symptom instead of the three required by the DSM-IV. Three is "too high for young children because they can’t show or express a lot of those internalized avoidance and numbing symptoms. It’s just developmentally impossible, like the sense of a foreshortened future – a child’s sense of future when they are 3 or 4 is tomorrow," he said at a psychopharmacology update sponsored by the American Academy of Child and Adolescent Psychiatry.

The increase in the number of young children likely to get the PTSD diagnosis under the new criteria is significant, because the illness historically has been underdiagnosed and missed in children, said Dr. Scheeringa, whose research contributed to the changes.

The DSM-IV requirement for irritability and anger outbursts also has been tweaked for preschoolers to include extreme temper tantrums, and the requirement for diminished interest in significant activities has been broadened to include restrictions in play and social interactions. "Young children don’t have jobs; they don’t have school; they don’t have hobbies. What they do is play and interact with other people; that’s where their interests would be diminished," he said.

"A skeptic might say, ‘Aren’t you just diagnosing mildly symptomatic kids? Aren’t you just lowering the bar?’ " but that doesn’t seem to be the case – the DSM-IV was simply missing small children with PTSD, he said.

In one of Dr. Scheeringa’s studies, DSM-IV criteria diagnosed PTSD in 13% of 284 trauma-exposed children aged 3-6 years; the DSM-5 criteria did so in about half, and those children had at least six symptoms (J. Trauma Stress 2012;25:359-67).

"Usually in treatment studies, they require five symptoms, so [these children] were really symptomatic. We’re not just diagnosing mildly symptomatic kids with" the new approach, Dr. Scheeringa said.

In general, psychotherapy – trauma-focused cognitive-behavioral therapy (CBT) in particular – is the first-line treatment for PTSD in both children and adults. "I would consider [psychiatric drugs] a distant second," he said. If needed, prazosin is likely to help with nightmares, benzodiazepines can take the edge off situational anxiety, and sleeping pills can calm fitful sleep. SSRIs might help with overall anxiety, he said.

Comorbid depression and other problems get better as PTSD resolves, "so I would suggest, based on the evidence, to focus on the PTSD first and then see what’s left over," Dr. Scheeringa said.

Attention-deficit/hyperactivity disorder (ADHD) is the exception; patients will do better in CBT if their ADHD is under control, he said.

Dr. Scheeringa said that he had no financial disclosures.

[email protected]

WASHINGTON – The DSM-5’s inclusion of separate criteria for posttraumatic stress disorder in preschool children probably will lead to more young children getting the diagnosis, which will be a positive development because PTSD is under-recognized in this population, Dr. Michael S. Scheeringa contended.

The preschool criteria are child friendly. Intrusive recollections, for instance, don’t have to be distressing, as in the adult criteria, because sometimes such recollections do not seem to bother very young kids. "They’ll bring up their intrusive recollections to the cashier at the supermarket and seem eager to talk about them, rather than distressed," he said.

Similarly, detachment and estrangement criteria have been "reworded to say ‘socially withdrawn,’ because children can’t verbalize that they feel detached, but it can be observed that they are socially withdrawn," said Dr. Scheeringa, a pediatric PTSD researcher who also serves as an associate professor of psychiatry and neurology at Tulane University in New Orleans.

Perhaps the biggest change is that preschool children – those below the age of 7 years – will need to show just one avoidance and numbing symptom instead of the three required by the DSM-IV. Three is "too high for young children because they can’t show or express a lot of those internalized avoidance and numbing symptoms. It’s just developmentally impossible, like the sense of a foreshortened future – a child’s sense of future when they are 3 or 4 is tomorrow," he said at a psychopharmacology update sponsored by the American Academy of Child and Adolescent Psychiatry.

The increase in the number of young children likely to get the PTSD diagnosis under the new criteria is significant, because the illness historically has been underdiagnosed and missed in children, said Dr. Scheeringa, whose research contributed to the changes.

The DSM-IV requirement for irritability and anger outbursts also has been tweaked for preschoolers to include extreme temper tantrums, and the requirement for diminished interest in significant activities has been broadened to include restrictions in play and social interactions. "Young children don’t have jobs; they don’t have school; they don’t have hobbies. What they do is play and interact with other people; that’s where their interests would be diminished," he said.

"A skeptic might say, ‘Aren’t you just diagnosing mildly symptomatic kids? Aren’t you just lowering the bar?’ " but that doesn’t seem to be the case – the DSM-IV was simply missing small children with PTSD, he said.

In one of Dr. Scheeringa’s studies, DSM-IV criteria diagnosed PTSD in 13% of 284 trauma-exposed children aged 3-6 years; the DSM-5 criteria did so in about half, and those children had at least six symptoms (J. Trauma Stress 2012;25:359-67).

"Usually in treatment studies, they require five symptoms, so [these children] were really symptomatic. We’re not just diagnosing mildly symptomatic kids with" the new approach, Dr. Scheeringa said.

In general, psychotherapy – trauma-focused cognitive-behavioral therapy (CBT) in particular – is the first-line treatment for PTSD in both children and adults. "I would consider [psychiatric drugs] a distant second," he said. If needed, prazosin is likely to help with nightmares, benzodiazepines can take the edge off situational anxiety, and sleeping pills can calm fitful sleep. SSRIs might help with overall anxiety, he said.

Comorbid depression and other problems get better as PTSD resolves, "so I would suggest, based on the evidence, to focus on the PTSD first and then see what’s left over," Dr. Scheeringa said.

Attention-deficit/hyperactivity disorder (ADHD) is the exception; patients will do better in CBT if their ADHD is under control, he said.

Dr. Scheeringa said that he had no financial disclosures.

[email protected]

If you are a child psychiatrist and haven’t heard of oxytocin for autism, you will.

Parents might soon ask you to put their autistic child on it, if they haven’t done so already, according to Lawrence Scahill, Ph.D.

"There’s a huge amount of interest in oxytocin. If you haven’t heard about this from your families, you will, believe me. It’s a hot topic," said Dr. Scahill, a pediatrics professor at Emory University and the Marcus Autism Center, both in Atlanta.

But "I’m not sure if [the interest] is warranted. There’s much, much more [that needs to be] learned about oxytocin," he said at the American Academy of Child and Adolescent Psychiatry’s Psychopharmacology Update Institute in Washington.

Some parents are getting the peptide hormone from compounding pharmacies and giving perhaps 18-24 IU intranasally to their autistic children daily in the hopes that it will help. But there’s just not enough data to know whether those children will benefit, or even whether oxytocin is safe to give to kids with autism.

Oxytocin plays an important role in child birth and lactation. Most agree it also has a role in emotion regulation and social interaction; the fact that plasma levels are low in autism has led "some to wonder if" supplements will help. "Ten minutes after a [24 IU] intranasal injection, plasma levels double" in autistic people. "They don’t normalize, but they double; the amount that gets through the blood-brain barrier is completely unclear at the moment," Dr. Scahill said (Proc. Natl. Acad. Sci. USA 2010;107:4389-94).

There’s also been "no great" human studies so far on benefit. In most, investigators gave single doses to healthy adults "and then did laboratory measurements of social interaction" with computer or gambling games. "That’s the state of the art," Dr. Scahill said.

Oxytocin seemed to increase trust in some of those studies. In another, a one-time dose of 18-24 IU appeared to slightly boost the ability of autistic boys to identify emotions from eye expressions, but it wasn’t "a very big effect," about a 5% increase in the number of correct answers, he said (Biol. Psychiatry 2010;67:692-4).

At this point, "we know next to nothing" about daily dosing, what parents are most likely to request. "If a parent said to me ‘I want my child on oxytocin,’ I would say we don’t know anything about how to dose it," and "as far as I know, it’s not been given to children younger than 12 in published studies. We don’t know anything about [using it in] young children," Dr. Scahill said.

Upcoming trials of oxytocin for autism should provide answers. Among them is a 5-year, multimillion dollar, National Institutes of Health–funded study that will test daily nasal dosing in 300 autistic children aged 3-17 years old.

In the meantime, Dr. Scahill reminded his audience that "in the 1990s, secretin was going to be the cure for autism" until a series of placebo-controlled studies showed no benefit. "Now it looks like oxytocin is the new cure. Is it really? I don’t know," he said.

For more information, he referred his audience to a recent investigation in the magazine Science (2013;339:267-9).

Dr. Scahill is a consultant for Biomarin and Roche. He also receives research funding form Pfizer, Roche, and Shire Pharmaceuticals.

BY M. ALEXANDER OTTO

[email protected]

Courtesy Wikimedia Commons/robin_24/Creative Commons License

If you are a child psychiatrist and haven’t heard of oxytocin for autism, you will.

Parents might soon ask you to put their autistic child on it, if they haven’t done so already, according to Lawrence Scahill, Ph.D.

"There’s a huge amount of interest in oxytocin. If you haven’t heard about this from your families, you will, believe me. It’s a hot topic," said Dr. Scahill, a pediatrics professor at Emory University and the Marcus Autism Center, both in Atlanta.

But "I’m not sure if [the interest] is warranted. There’s much, much more [that needs to be] learned about oxytocin," he said at the American Academy of Child and Adolescent Psychiatry’s Psychopharmacology Update Institute in Washington.

Some parents are getting the peptide hormone from compounding pharmacies and giving perhaps 18-24 IU intranasally to their autistic children daily in the hopes that it will help. But there’s just not enough data to know whether those children will benefit, or even whether oxytocin is safe to give to kids with autism.

Oxytocin plays an important role in child birth and lactation. Most agree it also has a role in emotion regulation and social interaction; the fact that plasma levels are low in autism has led "some to wonder if" supplements will help. "Ten minutes after a [24 IU] intranasal injection, plasma levels double" in autistic people. "They don’t normalize, but they double; the amount that gets through the blood-brain barrier is completely unclear at the moment," Dr. Scahill said (Proc. Natl. Acad. Sci. USA 2010;107:4389-94).

There’s also been "no great" human studies so far on benefit. In most, investigators gave single doses to healthy adults "and then did laboratory measurements of social interaction" with computer or gambling games. "That’s the state of the art," Dr. Scahill said.

Oxytocin seemed to increase trust in some of those studies. In another, a one-time dose of 18-24 IU appeared to slightly boost the ability of autistic boys to identify emotions from eye expressions, but it wasn’t "a very big effect," about a 5% increase in the number of correct answers, he said (Biol. Psychiatry 2010;67:692-4).

At this point, "we know next to nothing" about daily dosing, what parents are most likely to request. "If a parent said to me ‘I want my child on oxytocin,’ I would say we don’t know anything about how to dose it," and "as far as I know, it’s not been given to children younger than 12 in published studies. We don’t know anything about [using it in] young children," Dr. Scahill said.

Upcoming trials of oxytocin for autism should provide answers. Among them is a 5-year, multimillion dollar, National Institutes of Health–funded study that will test daily nasal dosing in 300 autistic children aged 3-17 years old.

In the meantime, Dr. Scahill reminded his audience that "in the 1990s, secretin was going to be the cure for autism" until a series of placebo-controlled studies showed no benefit. "Now it looks like oxytocin is the new cure. Is it really? I don’t know," he said.

For more information, he referred his audience to a recent investigation in the magazine Science (2013;339:267-9).

Dr. Scahill is a consultant for Biomarin and Roche. He also receives research funding form Pfizer, Roche, and Shire Pharmaceuticals.

BY M. ALEXANDER OTTO

[email protected]

Courtesy Wikimedia Commons/robin_24/Creative Commons License

If you are a child psychiatrist and haven’t heard of oxytocin for autism, you will.

Parents might soon ask you to put their autistic child on it, if they haven’t done so already, according to Lawrence Scahill, Ph.D.

"There’s a huge amount of interest in oxytocin. If you haven’t heard about this from your families, you will, believe me. It’s a hot topic," said Dr. Scahill, a pediatrics professor at Emory University and the Marcus Autism Center, both in Atlanta.

But "I’m not sure if [the interest] is warranted. There’s much, much more [that needs to be] learned about oxytocin," he said at the American Academy of Child and Adolescent Psychiatry’s Psychopharmacology Update Institute in Washington.

Some parents are getting the peptide hormone from compounding pharmacies and giving perhaps 18-24 IU intranasally to their autistic children daily in the hopes that it will help. But there’s just not enough data to know whether those children will benefit, or even whether oxytocin is safe to give to kids with autism.

Oxytocin plays an important role in child birth and lactation. Most agree it also has a role in emotion regulation and social interaction; the fact that plasma levels are low in autism has led "some to wonder if" supplements will help. "Ten minutes after a [24 IU] intranasal injection, plasma levels double" in autistic people. "They don’t normalize, but they double; the amount that gets through the blood-brain barrier is completely unclear at the moment," Dr. Scahill said (Proc. Natl. Acad. Sci. USA 2010;107:4389-94).

There’s also been "no great" human studies so far on benefit. In most, investigators gave single doses to healthy adults "and then did laboratory measurements of social interaction" with computer or gambling games. "That’s the state of the art," Dr. Scahill said.

Oxytocin seemed to increase trust in some of those studies. In another, a one-time dose of 18-24 IU appeared to slightly boost the ability of autistic boys to identify emotions from eye expressions, but it wasn’t "a very big effect," about a 5% increase in the number of correct answers, he said (Biol. Psychiatry 2010;67:692-4).

At this point, "we know next to nothing" about daily dosing, what parents are most likely to request. "If a parent said to me ‘I want my child on oxytocin,’ I would say we don’t know anything about how to dose it," and "as far as I know, it’s not been given to children younger than 12 in published studies. We don’t know anything about [using it in] young children," Dr. Scahill said.

Upcoming trials of oxytocin for autism should provide answers. Among them is a 5-year, multimillion dollar, National Institutes of Health–funded study that will test daily nasal dosing in 300 autistic children aged 3-17 years old.

In the meantime, Dr. Scahill reminded his audience that "in the 1990s, secretin was going to be the cure for autism" until a series of placebo-controlled studies showed no benefit. "Now it looks like oxytocin is the new cure. Is it really? I don’t know," he said.

For more information, he referred his audience to a recent investigation in the magazine Science (2013;339:267-9).

Dr. Scahill is a consultant for Biomarin and Roche. He also receives research funding form Pfizer, Roche, and Shire Pharmaceuticals.

BY M. ALEXANDER OTTO

[email protected]

Courtesy Wikimedia Commons/robin_24/Creative Commons License

If you are a child psychiatrist and haven’t heard of oxytocin for autism, you will.

Parents might soon ask you to put their autistic child on it, if they haven’t done so already, according to Lawrence Scahill, Ph.D.

"There’s a huge amount of interest in oxytocin. If you haven’t heard about this from your families, you will, believe me. It’s a hot topic," said Dr. Scahill, a pediatrics professor at Emory University and the Marcus Autism Center, both in Atlanta.

But "I’m not sure if [the interest] is warranted. There’s much, much more [that needs to be] learned about oxytocin," he said at the American Academy of Child and Adolescent Psychiatry’s Psychopharmacology Update Institute in Washington.

Some parents are getting the peptide hormone from compounding pharmacies and giving perhaps 18-24 IU intranasally to their autistic children daily in the hopes that it will help. But there’s just not enough data to know whether those children will benefit, or even whether oxytocin is safe to give to kids with autism.

Courtesy Wikimedia Commons/robin_24/Creative Commons License

Oxytocin plays an important role in child birth and lactation. Most agree it also has a role in emotion regulation and social interaction; the fact that plasma levels are low in autism has led "some to wonder if" supplements will help. "Ten minutes after a [24 IU] intranasal injection, plasma levels double" in autistic people. "They don’t normalize, but they double; the amount that gets through the blood-brain barrier is completely unclear at the moment," Dr. Scahill said (Proc. Natl. Acad. Sci. USA 2010;107:4389-94).

There’s also been "no great" human studies so far on benefit. In most, investigators gave single doses to healthy adults "and then did laboratory measurements of social interaction" with computer or gambling games. "That’s the state of the art," Dr. Scahill said.

Oxytocin seemed to increase trust in some of those studies. In another, a one-time dose of 18-24 IU appeared to slightly boost the ability of autistic boys to identify emotions from eye expressions, but it wasn’t "a very big effect," about a 5% increase in the number of correct answers, he said (Biol. Psychiatry 2010;67:692-4).

At this point, "we know next to nothing" about daily dosing, what parents are most likely to request. "If a parent said to me ‘I want my child on oxytocin,’ I would say we don’t know anything about how to dose it," and "as far as I know, it’s not been given to children younger than 12 in published studies. We don’t know anything about [using it in] young children," Dr. Scahill said.

Upcoming trials of oxytocin for autism should provide answers. Among them is a 5-year, multimillion dollar, National Institutes of Health–funded study that will test daily nasal dosing in 300 autistic children aged 3-17 years old.

In the meantime, Dr. Scahill reminded his audience that "in the 1990s, secretin was going to be the cure for autism" until a series of placebo-controlled studies showed no benefit. "Now it looks like oxytocin is the new cure. Is it really? I don’t know," he said.

For more information, he referred his audience to a recent investigation in the magazine Science (2013;339:267-9).

Dr. Scahill is a consultant for Biomarin and Roche. He also receives research funding form Pfizer, Roche, and Shire Pharmaceuticals.

--BY M. ALEXANDER OTTO

[email protected]

If you are a child psychiatrist and haven’t heard of oxytocin for autism, you will.

Parents might soon ask you to put their autistic child on it, if they haven’t done so already, according to Lawrence Scahill, Ph.D.

"There’s a huge amount of interest in oxytocin. If you haven’t heard about this from your families, you will, believe me. It’s a hot topic," said Dr. Scahill, a pediatrics professor at Emory University and the Marcus Autism Center, both in Atlanta.

But "I’m not sure if [the interest] is warranted. There’s much, much more [that needs to be] learned about oxytocin," he said at the American Academy of Child and Adolescent Psychiatry’s Psychopharmacology Update Institute in Washington.

Some parents are getting the peptide hormone from compounding pharmacies and giving perhaps 18-24 IU intranasally to their autistic children daily in the hopes that it will help. But there’s just not enough data to know whether those children will benefit, or even whether oxytocin is safe to give to kids with autism.

Courtesy Wikimedia Commons/robin_24/Creative Commons License

Oxytocin plays an important role in child birth and lactation. Most agree it also has a role in emotion regulation and social interaction; the fact that plasma levels are low in autism has led "some to wonder if" supplements will help. "Ten minutes after a [24 IU] intranasal injection, plasma levels double" in autistic people. "They don’t normalize, but they double; the amount that gets through the blood-brain barrier is completely unclear at the moment," Dr. Scahill said (Proc. Natl. Acad. Sci. USA 2010;107:4389-94).

There’s also been "no great" human studies so far on benefit. In most, investigators gave single doses to healthy adults "and then did laboratory measurements of social interaction" with computer or gambling games. "That’s the state of the art," Dr. Scahill said.

Oxytocin seemed to increase trust in some of those studies. In another, a one-time dose of 18-24 IU appeared to slightly boost the ability of autistic boys to identify emotions from eye expressions, but it wasn’t "a very big effect," about a 5% increase in the number of correct answers, he said (Biol. Psychiatry 2010;67:692-4).

At this point, "we know next to nothing" about daily dosing, what parents are most likely to request. "If a parent said to me ‘I want my child on oxytocin,’ I would say we don’t know anything about how to dose it," and "as far as I know, it’s not been given to children younger than 12 in published studies. We don’t know anything about [using it in] young children," Dr. Scahill said.

Upcoming trials of oxytocin for autism should provide answers. Among them is a 5-year, multimillion dollar, National Institutes of Health–funded study that will test daily nasal dosing in 300 autistic children aged 3-17 years old.

In the meantime, Dr. Scahill reminded his audience that "in the 1990s, secretin was going to be the cure for autism" until a series of placebo-controlled studies showed no benefit. "Now it looks like oxytocin is the new cure. Is it really? I don’t know," he said.

For more information, he referred his audience to a recent investigation in the magazine Science (2013;339:267-9).

Dr. Scahill is a consultant for Biomarin and Roche. He also receives research funding form Pfizer, Roche, and Shire Pharmaceuticals.

--BY M. ALEXANDER OTTO

[email protected]

If you are a child psychiatrist and haven’t heard of oxytocin for autism, you will.

Parents might soon ask you to put their autistic child on it, if they haven’t done so already, according to Lawrence Scahill, Ph.D.

"There’s a huge amount of interest in oxytocin. If you haven’t heard about this from your families, you will, believe me. It’s a hot topic," said Dr. Scahill, a pediatrics professor at Emory University and the Marcus Autism Center, both in Atlanta.

But "I’m not sure if [the interest] is warranted. There’s much, much more [that needs to be] learned about oxytocin," he said at the American Academy of Child and Adolescent Psychiatry’s Psychopharmacology Update Institute in Washington.

Some parents are getting the peptide hormone from compounding pharmacies and giving perhaps 18-24 IU intranasally to their autistic children daily in the hopes that it will help. But there’s just not enough data to know whether those children will benefit, or even whether oxytocin is safe to give to kids with autism.

Courtesy Wikimedia Commons/robin_24/Creative Commons License

Oxytocin plays an important role in child birth and lactation. Most agree it also has a role in emotion regulation and social interaction; the fact that plasma levels are low in autism has led "some to wonder if" supplements will help. "Ten minutes after a [24 IU] intranasal injection, plasma levels double" in autistic people. "They don’t normalize, but they double; the amount that gets through the blood-brain barrier is completely unclear at the moment," Dr. Scahill said (Proc. Natl. Acad. Sci. USA 2010;107:4389-94).

There’s also been "no great" human studies so far on benefit. In most, investigators gave single doses to healthy adults "and then did laboratory measurements of social interaction" with computer or gambling games. "That’s the state of the art," Dr. Scahill said.

Oxytocin seemed to increase trust in some of those studies. In another, a one-time dose of 18-24 IU appeared to slightly boost the ability of autistic boys to identify emotions from eye expressions, but it wasn’t "a very big effect," about a 5% increase in the number of correct answers, he said (Biol. Psychiatry 2010;67:692-4).

At this point, "we know next to nothing" about daily dosing, what parents are most likely to request. "If a parent said to me ‘I want my child on oxytocin,’ I would say we don’t know anything about how to dose it," and "as far as I know, it’s not been given to children younger than 12 in published studies. We don’t know anything about [using it in] young children," Dr. Scahill said.

Upcoming trials of oxytocin for autism should provide answers. Among them is a 5-year, multimillion dollar, National Institutes of Health–funded study that will test daily nasal dosing in 300 autistic children aged 3-17 years old.

In the meantime, Dr. Scahill reminded his audience that "in the 1990s, secretin was going to be the cure for autism" until a series of placebo-controlled studies showed no benefit. "Now it looks like oxytocin is the new cure. Is it really? I don’t know," he said.

For more information, he referred his audience to a recent investigation in the magazine Science (2013;339:267-9).

Dr. Scahill is a consultant for Biomarin and Roche. He also receives research funding form Pfizer, Roche, and Shire Pharmaceuticals.

--BY M. ALEXANDER OTTO

[email protected]

WASHINGTON – Children diagnosed with pervasive developmental disorder not otherwise specified probably will not meet the criteria for an autism diagnosis under the DSM-5, according to Lawrence Scahill, Ph.D.

"I don’t think schools are going to rearrange labels, but down the road, children we call PDD-NOS [pervasive developmental disorder not otherwise specified] are going to be harder to fit into the new criteria" when the DSM-5 is published in May, said Dr. Scahill, a pediatrics professor at Emory University and the Marcus Autism Center, both in Atlanta.

For some children repetitive behaviors and language, and social delays, will not be "profound [enough]. [Instead,] maybe they’ll get some of what they need by a diagnosis of ADHD," Dr. Scahill said at a psychopharmacology update, sponsored by the American Academy of Child and Adolescent Psychiatry.

The DSM-5’s autism requirements are more restrictive than those of the DSM-IV. For example, in the new manual, autism, Asperger’s syndrome, and PDD-NOS will be lumped together under a single diagnosis of autism spectrum disorder, which is likely to require, among other things, early onset of social communication and interaction deficits, restricted interests, and repetitive behavior, plus an indication of severity level.

The idea is to make the diagnosis of autism more precise. Under the DSM-IV’s more subjective requirements, clinicians could have valid disagreements about where to slot a child, said Dr. Scahill, who formerly served as director of the Research Unit on Pediatric Psychopharmacology at the Yale Child Study Center, New Haven, Conn.

In addition, "a large amount of genetic research from twin studies supports the idea of a spectrum disorder. [Often,] twin one has full autism and twin two has a pastel version, [especially] in monozygotic twins," he said.

The changes will probably decrease the prevalence of autism if people "are careful in their diagnoses," Dr. Scahill said. Many PDD-NOS children will better fit DSM-5’s new "social communication language disorder." The DSM-5s drafters were "trying to get kids with delayed language out of autism," he noted.

Asperger’s is going away, too, which has caused "a great hue and cry from [the Asperger’s] community. They say things like ‘it’s helped me understand myself’ and feel like they won’t have that explanation [anymore], but I don’t think that many kids with [true] Asperger’s will fail to meet the criteria for autism spectrum disorder. There are people who have been given an Asperger’s diagnosis who might not meet it; they might have been overdiagnosed. I don’t think [the change] is as harmful as some think," he said.

The DSM-5 also will allow patients with autistic disorder to be diagnosed with attention-deficit/hyperactivity disorder (ADHD); the DSM-IV specifies that such a dual diagnosis is not made.

In general, ADHD drugs are less effective in children with autism and more likely to cause side effects, Dr. Scahill said.

"Methylphenidate has small to medium effects. Tolerabilities are okay at conservative doses. Study results are mixed" on whether atomoxetine helps or not, but "I wouldn’t say don’t try it. We need more data on guanfacine." Small studies on clonidine suggest children with autistic disorder "are exquisitely sensitive to its sedative side effects," he said.

"When dealing with parents, be up-front and say, ‘We are looking for some help here, but we are not expecting big effects.’ If we can get some benefit at low and medium doses, we’re going to take the money and run," he said.

Dr. Scahill is a consultant for Biomarin and Roche. He also receives research funding from Pfizer, Roche, and Shire Pharmaceuticals.

WASHINGTON – Children diagnosed with pervasive developmental disorder not otherwise specified probably will not meet the criteria for an autism diagnosis under the DSM-5, according to Lawrence Scahill, Ph.D.

"I don’t think schools are going to rearrange labels, but down the road, children we call PDD-NOS [pervasive developmental disorder not otherwise specified] are going to be harder to fit into the new criteria" when the DSM-5 is published in May, said Dr. Scahill, a pediatrics professor at Emory University and the Marcus Autism Center, both in Atlanta.

For some children repetitive behaviors and language, and social delays, will not be "profound [enough]. [Instead,] maybe they’ll get some of what they need by a diagnosis of ADHD," Dr. Scahill said at a psychopharmacology update, sponsored by the American Academy of Child and Adolescent Psychiatry.

The DSM-5’s autism requirements are more restrictive than those of the DSM-IV. For example, in the new manual, autism, Asperger’s syndrome, and PDD-NOS will be lumped together under a single diagnosis of autism spectrum disorder, which is likely to require, among other things, early onset of social communication and interaction deficits, restricted interests, and repetitive behavior, plus an indication of severity level.

The idea is to make the diagnosis of autism more precise. Under the DSM-IV’s more subjective requirements, clinicians could have valid disagreements about where to slot a child, said Dr. Scahill, who formerly served as director of the Research Unit on Pediatric Psychopharmacology at the Yale Child Study Center, New Haven, Conn.

In addition, "a large amount of genetic research from twin studies supports the idea of a spectrum disorder. [Often,] twin one has full autism and twin two has a pastel version, [especially] in monozygotic twins," he said.

The changes will probably decrease the prevalence of autism if people "are careful in their diagnoses," Dr. Scahill said. Many PDD-NOS children will better fit DSM-5’s new "social communication language disorder." The DSM-5s drafters were "trying to get kids with delayed language out of autism," he noted.

Asperger’s is going away, too, which has caused "a great hue and cry from [the Asperger’s] community. They say things like ‘it’s helped me understand myself’ and feel like they won’t have that explanation [anymore], but I don’t think that many kids with [true] Asperger’s will fail to meet the criteria for autism spectrum disorder. There are people who have been given an Asperger’s diagnosis who might not meet it; they might have been overdiagnosed. I don’t think [the change] is as harmful as some think," he said.

The DSM-5 also will allow patients with autistic disorder to be diagnosed with attention-deficit/hyperactivity disorder (ADHD); the DSM-IV specifies that such a dual diagnosis is not made.

In general, ADHD drugs are less effective in children with autism and more likely to cause side effects, Dr. Scahill said.

"Methylphenidate has small to medium effects. Tolerabilities are okay at conservative doses. Study results are mixed" on whether atomoxetine helps or not, but "I wouldn’t say don’t try it. We need more data on guanfacine." Small studies on clonidine suggest children with autistic disorder "are exquisitely sensitive to its sedative side effects," he said.

"When dealing with parents, be up-front and say, ‘We are looking for some help here, but we are not expecting big effects.’ If we can get some benefit at low and medium doses, we’re going to take the money and run," he said.

Dr. Scahill is a consultant for Biomarin and Roche. He also receives research funding from Pfizer, Roche, and Shire Pharmaceuticals.

WASHINGTON – Children diagnosed with pervasive developmental disorder not otherwise specified probably will not meet the criteria for an autism diagnosis under the DSM-5, according to Lawrence Scahill, Ph.D.

"I don’t think schools are going to rearrange labels, but down the road, children we call PDD-NOS [pervasive developmental disorder not otherwise specified] are going to be harder to fit into the new criteria" when the DSM-5 is published in May, said Dr. Scahill, a pediatrics professor at Emory University and the Marcus Autism Center, both in Atlanta.

For some children repetitive behaviors and language, and social delays, will not be "profound [enough]. [Instead,] maybe they’ll get some of what they need by a diagnosis of ADHD," Dr. Scahill said at a psychopharmacology update, sponsored by the American Academy of Child and Adolescent Psychiatry.

The DSM-5’s autism requirements are more restrictive than those of the DSM-IV. For example, in the new manual, autism, Asperger’s syndrome, and PDD-NOS will be lumped together under a single diagnosis of autism spectrum disorder, which is likely to require, among other things, early onset of social communication and interaction deficits, restricted interests, and repetitive behavior, plus an indication of severity level.

The idea is to make the diagnosis of autism more precise. Under the DSM-IV’s more subjective requirements, clinicians could have valid disagreements about where to slot a child, said Dr. Scahill, who formerly served as director of the Research Unit on Pediatric Psychopharmacology at the Yale Child Study Center, New Haven, Conn.

In addition, "a large amount of genetic research from twin studies supports the idea of a spectrum disorder. [Often,] twin one has full autism and twin two has a pastel version, [especially] in monozygotic twins," he said.

The changes will probably decrease the prevalence of autism if people "are careful in their diagnoses," Dr. Scahill said. Many PDD-NOS children will better fit DSM-5’s new "social communication language disorder." The DSM-5s drafters were "trying to get kids with delayed language out of autism," he noted.

Asperger’s is going away, too, which has caused "a great hue and cry from [the Asperger’s] community. They say things like ‘it’s helped me understand myself’ and feel like they won’t have that explanation [anymore], but I don’t think that many kids with [true] Asperger’s will fail to meet the criteria for autism spectrum disorder. There are people who have been given an Asperger’s diagnosis who might not meet it; they might have been overdiagnosed. I don’t think [the change] is as harmful as some think," he said.

The DSM-5 also will allow patients with autistic disorder to be diagnosed with attention-deficit/hyperactivity disorder (ADHD); the DSM-IV specifies that such a dual diagnosis is not made.

In general, ADHD drugs are less effective in children with autism and more likely to cause side effects, Dr. Scahill said.

"Methylphenidate has small to medium effects. Tolerabilities are okay at conservative doses. Study results are mixed" on whether atomoxetine helps or not, but "I wouldn’t say don’t try it. We need more data on guanfacine." Small studies on clonidine suggest children with autistic disorder "are exquisitely sensitive to its sedative side effects," he said.

"When dealing with parents, be up-front and say, ‘We are looking for some help here, but we are not expecting big effects.’ If we can get some benefit at low and medium doses, we’re going to take the money and run," he said.

Dr. Scahill is a consultant for Biomarin and Roche. He also receives research funding from Pfizer, Roche, and Shire Pharmaceuticals.

The DSM-5’s new diagnosis of disruptive mood dysregulation disorder was made to address the overdiagnosis of bipolar disorder by creating a diagnostic home for children with explosive rages, but only some of those children will qualify for the diagnosis, according to Dr. Gabrielle A. Carlson.

It "will relieve [only] some of the stress" on bipolar disorder, but "it won’t solve all the problems of false diagnosis," she said at a psychopharmacology update, sponsored by the American Academy of Child and Adolescent Psychiatry.

When the DSM-5 is published in May, disruptive mood dysregulation disorder (DMDD) probably will require at least 12 months of very severe outbursts from trivial triggers that happen more than three times per week and are developmentally inappropriate; persistently irritable mood between outbursts most of the day every day; outbursts or negative mood in at least two separate settings; and onset before the age of 10, among other criteria.

"And there are a number of really important exclusionary criteria. You don’t see [DMDD] if there’s any hint of mania, if there’s major depressive disorder," or if there is dysthymia, psychosis, posttraumatic stress disorder (PTSD), pervasive developmental disorders, or separation anxiety, said Dr. Carlson, director of child and adolescent psychiatry at the State University of New York at Stony Brook.

"Here’s the problem: Many children with explosive outbursts have depression and dysthymia, or PTSD," or some other exclusionary problem, or don’t meet all of the DMDD requirements. "If we follow the rules," only about 25% of inpatient explosive children and a fifth of children on the outpatient side will have DMDD, she said, based on analyses of her own inpatient and outpatient services.

Having a diagnostic home and treatment focus for explosive children is probably a positive development, Dr. Carlson said, because rages are probably the "single most vexing problem we have in child psychiatry. On the other hand, [DMDD] is just as likely to be abused as bipolar disorder, because it doesn’t capture the vast majority of kids with explosive outbursts. In fact, it may well mask conditions we already know about and can treat. If you go rushing right to ‘whoa, explosive outbursts – DMDD,’ you’re not going to look for depression, you are not going to look for ADHD, you’re not going to look for stuff you can treat," Dr. Carlson said.

Remember that "kids [with explosive outbursts] are doing the best they can," she said. "They aren’t getting up in the morning saying, ‘I’m really going to try to anger my parents and teachers.’ "

It’s important to first "maximize treatment of the base condition, whether it’s ADHD, depression, or some other problem." If outbursts remain a symptom, consider adding an atypical or conventional antipsychotic or a mood stabilizer, she said. It might take a while to see benefit, so "keep a record of the frequency, duration, and intensity of outbursts" to show parents that progress is being made.

"Medication is for executive functioning and mood regulation. For language and social" problems, it’s about psychoeducation – trying to understand the rage triggers and how not to feed them. Parent training can help. In addition, "if a parent has a psychiatric disorder, get it treated." Parents will not be able to help their child – and follow through on treatment recommendations – if they don’t have their own issues under control.

Dr. Carlson disclosed research funding from Pfizer, GlaxoSmithKline, Schering-Plough, Bristol-Myers Squibb, and Otsuka.

The DSM-5’s new diagnosis of disruptive mood dysregulation disorder was made to address the overdiagnosis of bipolar disorder by creating a diagnostic home for children with explosive rages, but only some of those children will qualify for the diagnosis, according to Dr. Gabrielle A. Carlson.

It "will relieve [only] some of the stress" on bipolar disorder, but "it won’t solve all the problems of false diagnosis," she said at a psychopharmacology update, sponsored by the American Academy of Child and Adolescent Psychiatry.

When the DSM-5 is published in May, disruptive mood dysregulation disorder (DMDD) probably will require at least 12 months of very severe outbursts from trivial triggers that happen more than three times per week and are developmentally inappropriate; persistently irritable mood between outbursts most of the day every day; outbursts or negative mood in at least two separate settings; and onset before the age of 10, among other criteria.

"And there are a number of really important exclusionary criteria. You don’t see [DMDD] if there’s any hint of mania, if there’s major depressive disorder," or if there is dysthymia, psychosis, posttraumatic stress disorder (PTSD), pervasive developmental disorders, or separation anxiety, said Dr. Carlson, director of child and adolescent psychiatry at the State University of New York at Stony Brook.

"Here’s the problem: Many children with explosive outbursts have depression and dysthymia, or PTSD," or some other exclusionary problem, or don’t meet all of the DMDD requirements. "If we follow the rules," only about 25% of inpatient explosive children and a fifth of children on the outpatient side will have DMDD, she said, based on analyses of her own inpatient and outpatient services.

Having a diagnostic home and treatment focus for explosive children is probably a positive development, Dr. Carlson said, because rages are probably the "single most vexing problem we have in child psychiatry. On the other hand, [DMDD] is just as likely to be abused as bipolar disorder, because it doesn’t capture the vast majority of kids with explosive outbursts. In fact, it may well mask conditions we already know about and can treat. If you go rushing right to ‘whoa, explosive outbursts – DMDD,’ you’re not going to look for depression, you are not going to look for ADHD, you’re not going to look for stuff you can treat," Dr. Carlson said.

Remember that "kids [with explosive outbursts] are doing the best they can," she said. "They aren’t getting up in the morning saying, ‘I’m really going to try to anger my parents and teachers.’ "

It’s important to first "maximize treatment of the base condition, whether it’s ADHD, depression, or some other problem." If outbursts remain a symptom, consider adding an atypical or conventional antipsychotic or a mood stabilizer, she said. It might take a while to see benefit, so "keep a record of the frequency, duration, and intensity of outbursts" to show parents that progress is being made.

"Medication is for executive functioning and mood regulation. For language and social" problems, it’s about psychoeducation – trying to understand the rage triggers and how not to feed them. Parent training can help. In addition, "if a parent has a psychiatric disorder, get it treated." Parents will not be able to help their child – and follow through on treatment recommendations – if they don’t have their own issues under control.

Dr. Carlson disclosed research funding from Pfizer, GlaxoSmithKline, Schering-Plough, Bristol-Myers Squibb, and Otsuka.

The DSM-5’s new diagnosis of disruptive mood dysregulation disorder was made to address the overdiagnosis of bipolar disorder by creating a diagnostic home for children with explosive rages, but only some of those children will qualify for the diagnosis, according to Dr. Gabrielle A. Carlson.

It "will relieve [only] some of the stress" on bipolar disorder, but "it won’t solve all the problems of false diagnosis," she said at a psychopharmacology update, sponsored by the American Academy of Child and Adolescent Psychiatry.

When the DSM-5 is published in May, disruptive mood dysregulation disorder (DMDD) probably will require at least 12 months of very severe outbursts from trivial triggers that happen more than three times per week and are developmentally inappropriate; persistently irritable mood between outbursts most of the day every day; outbursts or negative mood in at least two separate settings; and onset before the age of 10, among other criteria.

"And there are a number of really important exclusionary criteria. You don’t see [DMDD] if there’s any hint of mania, if there’s major depressive disorder," or if there is dysthymia, psychosis, posttraumatic stress disorder (PTSD), pervasive developmental disorders, or separation anxiety, said Dr. Carlson, director of child and adolescent psychiatry at the State University of New York at Stony Brook.

"Here’s the problem: Many children with explosive outbursts have depression and dysthymia, or PTSD," or some other exclusionary problem, or don’t meet all of the DMDD requirements. "If we follow the rules," only about 25% of inpatient explosive children and a fifth of children on the outpatient side will have DMDD, she said, based on analyses of her own inpatient and outpatient services.

Having a diagnostic home and treatment focus for explosive children is probably a positive development, Dr. Carlson said, because rages are probably the "single most vexing problem we have in child psychiatry. On the other hand, [DMDD] is just as likely to be abused as bipolar disorder, because it doesn’t capture the vast majority of kids with explosive outbursts. In fact, it may well mask conditions we already know about and can treat. If you go rushing right to ‘whoa, explosive outbursts – DMDD,’ you’re not going to look for depression, you are not going to look for ADHD, you’re not going to look for stuff you can treat," Dr. Carlson said.

Remember that "kids [with explosive outbursts] are doing the best they can," she said. "They aren’t getting up in the morning saying, ‘I’m really going to try to anger my parents and teachers.’ "

It’s important to first "maximize treatment of the base condition, whether it’s ADHD, depression, or some other problem." If outbursts remain a symptom, consider adding an atypical or conventional antipsychotic or a mood stabilizer, she said. It might take a while to see benefit, so "keep a record of the frequency, duration, and intensity of outbursts" to show parents that progress is being made.

"Medication is for executive functioning and mood regulation. For language and social" problems, it’s about psychoeducation – trying to understand the rage triggers and how not to feed them. Parent training can help. In addition, "if a parent has a psychiatric disorder, get it treated." Parents will not be able to help their child – and follow through on treatment recommendations – if they don’t have their own issues under control.

Dr. Carlson disclosed research funding from Pfizer, GlaxoSmithKline, Schering-Plough, Bristol-Myers Squibb, and Otsuka.