American Academy of Child and Adolescent Psychiatry (AACAP): Annual Meeting

SAN FRANCISCO – The foundational beliefs of American Indian and Alaska Native communities play a key role in innovative substance abuse treatment programs, research has shown.

That’s a novel finding that could challenge conventional notions of culturally based care, Dr. Douglas K. Novins said at the annual meeting of the American Academy of Child and Adolescent Psychiatry.

In an ongoing study, he conducted hour-long interviews with 20 administrators and 15 focus groups with clinicians lasting 90 minutes each at 18 alcohol and substance abuse treatment programs serving American Indian and Alaska Native communities. The programs were chosen by an advisory board on the basis of their reputations for innovative services and to ensure a diversity of programs in the study.

Dr. Novins and his associates found that the programs included traditional practices and Western models of treatment, as has been reported in previous studies. The traditional practices might include crafts or jewelry making, drumming, singing, or fishing by bringing in tribal elders or Native American occupational therapists. The Western element typically included something similar to 12-step programs. That merging of 12-step approaches and traditional practices has been controversial among some American Indian and Alaska Native people.

The new finding is the emphasis that these programs place on the foundational beliefs of their cultures – the importance of community and family, meaningful relationships with clients and respect for clients, a homelike atmosphere in the program setting, and an open door policy that never turns clients away (Psychiatr. Serv. 2012;63:686-92).

These core values validate and incorporate the world view of American Indian and Alaska Native cultures, which see individuals as contained in a circle of family, within a circle of community, within a circle of the spirit world. "Many Native peoples will tell you that substance abuse is a sign of broken circles," said Dr. Novins of the University of Colorado, Aurora.

Previous research suggests that the long history of multigenerational traumas experienced by Native Americans as their cultures have been eradicated by nonnatives is a primary cause of substance abuse, he said. Almost all the programs studied incorporate Wellbriety (a treatment model that tries to merge 12-step treatment approaches with Native American beliefs and culture), but the programs made informal adjustments as they went along, Dr. Novins said. They addressed the historical trauma of Native Americans and incorporated culturally specific images, medicine wheels, and circles.

There are many challenges to basing treatment on the fundamental beliefs and values of Native peoples. The open-door policy, especially, "is tough if you come from an allopathic place," he said. Cultural competence in this regard means not turning away someone who comes to you without an appointment. You see them or ask them to wait until you’re done with what you’re doing, and then see them. It means that when a client telephones to say the police are at his house and he wants you to come talk to them, you go, he said.

The great diversity of Native tribes and their general lack of resources also create challenges to disseminating these innovative treatment models. There is great pressure to implement evidence-based practices, clinician burnout is a problem, and the socioeconomic hurdles might seem insurmountable. The success of substance abuse treatment programs might depend on blending evidence-based practices with the Native American cultural emphasis on community, family, relationships, and respect, Dr. Novins said.

Ten of the programs in the study are on reservations, three are in nonreservation rural areas, and five are in urban areas, where most Native American people live today. Only approximately 2% of the Indian Health Service budget goes to urban areas, Dr. Novins noted.

Participants in the study’s interviews received up to $300 worth of educational and clinical materials of each program’s choosing.

The investigators now are finishing the final phase of the study – a survey of 193 tribal substance abuse and treatment programs across the United States.

Dr. Novins reported that he had no relevant financial disclosures. The National Institute on Drug Abuse is funding this research.

[email protected]

On Twitter @sherryboschert

SAN FRANCISCO – The foundational beliefs of American Indian and Alaska Native communities play a key role in innovative substance abuse treatment programs, research has shown.

That’s a novel finding that could challenge conventional notions of culturally based care, Dr. Douglas K. Novins said at the annual meeting of the American Academy of Child and Adolescent Psychiatry.

In an ongoing study, he conducted hour-long interviews with 20 administrators and 15 focus groups with clinicians lasting 90 minutes each at 18 alcohol and substance abuse treatment programs serving American Indian and Alaska Native communities. The programs were chosen by an advisory board on the basis of their reputations for innovative services and to ensure a diversity of programs in the study.

Dr. Novins and his associates found that the programs included traditional practices and Western models of treatment, as has been reported in previous studies. The traditional practices might include crafts or jewelry making, drumming, singing, or fishing by bringing in tribal elders or Native American occupational therapists. The Western element typically included something similar to 12-step programs. That merging of 12-step approaches and traditional practices has been controversial among some American Indian and Alaska Native people.

The new finding is the emphasis that these programs place on the foundational beliefs of their cultures – the importance of community and family, meaningful relationships with clients and respect for clients, a homelike atmosphere in the program setting, and an open door policy that never turns clients away (Psychiatr. Serv. 2012;63:686-92).

These core values validate and incorporate the world view of American Indian and Alaska Native cultures, which see individuals as contained in a circle of family, within a circle of community, within a circle of the spirit world. "Many Native peoples will tell you that substance abuse is a sign of broken circles," said Dr. Novins of the University of Colorado, Aurora.

Previous research suggests that the long history of multigenerational traumas experienced by Native Americans as their cultures have been eradicated by nonnatives is a primary cause of substance abuse, he said. Almost all the programs studied incorporate Wellbriety (a treatment model that tries to merge 12-step treatment approaches with Native American beliefs and culture), but the programs made informal adjustments as they went along, Dr. Novins said. They addressed the historical trauma of Native Americans and incorporated culturally specific images, medicine wheels, and circles.

There are many challenges to basing treatment on the fundamental beliefs and values of Native peoples. The open-door policy, especially, "is tough if you come from an allopathic place," he said. Cultural competence in this regard means not turning away someone who comes to you without an appointment. You see them or ask them to wait until you’re done with what you’re doing, and then see them. It means that when a client telephones to say the police are at his house and he wants you to come talk to them, you go, he said.

The great diversity of Native tribes and their general lack of resources also create challenges to disseminating these innovative treatment models. There is great pressure to implement evidence-based practices, clinician burnout is a problem, and the socioeconomic hurdles might seem insurmountable. The success of substance abuse treatment programs might depend on blending evidence-based practices with the Native American cultural emphasis on community, family, relationships, and respect, Dr. Novins said.

Ten of the programs in the study are on reservations, three are in nonreservation rural areas, and five are in urban areas, where most Native American people live today. Only approximately 2% of the Indian Health Service budget goes to urban areas, Dr. Novins noted.

Participants in the study’s interviews received up to $300 worth of educational and clinical materials of each program’s choosing.

The investigators now are finishing the final phase of the study – a survey of 193 tribal substance abuse and treatment programs across the United States.

Dr. Novins reported that he had no relevant financial disclosures. The National Institute on Drug Abuse is funding this research.

[email protected]

On Twitter @sherryboschert

SAN FRANCISCO – The foundational beliefs of American Indian and Alaska Native communities play a key role in innovative substance abuse treatment programs, research has shown.

That’s a novel finding that could challenge conventional notions of culturally based care, Dr. Douglas K. Novins said at the annual meeting of the American Academy of Child and Adolescent Psychiatry.

In an ongoing study, he conducted hour-long interviews with 20 administrators and 15 focus groups with clinicians lasting 90 minutes each at 18 alcohol and substance abuse treatment programs serving American Indian and Alaska Native communities. The programs were chosen by an advisory board on the basis of their reputations for innovative services and to ensure a diversity of programs in the study.

Dr. Novins and his associates found that the programs included traditional practices and Western models of treatment, as has been reported in previous studies. The traditional practices might include crafts or jewelry making, drumming, singing, or fishing by bringing in tribal elders or Native American occupational therapists. The Western element typically included something similar to 12-step programs. That merging of 12-step approaches and traditional practices has been controversial among some American Indian and Alaska Native people.

The new finding is the emphasis that these programs place on the foundational beliefs of their cultures – the importance of community and family, meaningful relationships with clients and respect for clients, a homelike atmosphere in the program setting, and an open door policy that never turns clients away (Psychiatr. Serv. 2012;63:686-92).

These core values validate and incorporate the world view of American Indian and Alaska Native cultures, which see individuals as contained in a circle of family, within a circle of community, within a circle of the spirit world. "Many Native peoples will tell you that substance abuse is a sign of broken circles," said Dr. Novins of the University of Colorado, Aurora.

Previous research suggests that the long history of multigenerational traumas experienced by Native Americans as their cultures have been eradicated by nonnatives is a primary cause of substance abuse, he said. Almost all the programs studied incorporate Wellbriety (a treatment model that tries to merge 12-step treatment approaches with Native American beliefs and culture), but the programs made informal adjustments as they went along, Dr. Novins said. They addressed the historical trauma of Native Americans and incorporated culturally specific images, medicine wheels, and circles.

There are many challenges to basing treatment on the fundamental beliefs and values of Native peoples. The open-door policy, especially, "is tough if you come from an allopathic place," he said. Cultural competence in this regard means not turning away someone who comes to you without an appointment. You see them or ask them to wait until you’re done with what you’re doing, and then see them. It means that when a client telephones to say the police are at his house and he wants you to come talk to them, you go, he said.

The great diversity of Native tribes and their general lack of resources also create challenges to disseminating these innovative treatment models. There is great pressure to implement evidence-based practices, clinician burnout is a problem, and the socioeconomic hurdles might seem insurmountable. The success of substance abuse treatment programs might depend on blending evidence-based practices with the Native American cultural emphasis on community, family, relationships, and respect, Dr. Novins said.

Ten of the programs in the study are on reservations, three are in nonreservation rural areas, and five are in urban areas, where most Native American people live today. Only approximately 2% of the Indian Health Service budget goes to urban areas, Dr. Novins noted.

Participants in the study’s interviews received up to $300 worth of educational and clinical materials of each program’s choosing.

The investigators now are finishing the final phase of the study – a survey of 193 tribal substance abuse and treatment programs across the United States.

Dr. Novins reported that he had no relevant financial disclosures. The National Institute on Drug Abuse is funding this research.

[email protected]

On Twitter @sherryboschert

Suicide attempts or ideation were a problem in 43% of autistic children compared with 14% of depressed nonautistic children and 0.5% of children with neither depression nor autism, in a prospective study of 1,012 children.

Mothers of the children rated 165 items on the Pediatric Behavior Scale from "not at all a problem" to "very often a problem." Suicide ideation and attempts were considered a problem if they occurred anywhere from sometimes to very often.

"Because suicide ideation and attempts in autism are significantly higher than the norm, all children with autism should be screened for suicide ideation or attempts," Angela A. Gorman, Ph.D., said at a poster presentation at the annual meeting of the American Academy of Child and Adolescent Psychiatry.

Among the 179 autistic children, 77% of those with suicide ideation or attempts were depressed, but only 28% of those with depression had suicide ideation or attempts. Among autistic children without depression, 95% had no suicide ideation or attempts, reported Dr. Gorman, a clinical psychologist in the department of psychiatry at Pennsylvania State College of Medicine, Hershey, and her associates.

The autistic children ranged in age from 1 to 16 years; 68% had high-function autism (defined as an IQ of 80 or higher), and the rest had low-functioning autism. The 35 nonautistic children with depression ranged in age from 8 to 16 years, and the 186 typical children were 6-12 years old.

Males comprised 84% of the autistic group, 26% of the nonautistic depressed group, and 44% of the typical group. The proportions of parents whose occupations were professional or managerial (indicating higher socioeconomic status) were 37% in the autistic group, 51% in the nonautistic with depression, and 51% in the typical group. The study cohort came mainly from rural, central Pennsylvania, where white children made up 92% of the autistic group, 94% of the nonautistic with depression, and 78% of the typical group.

The study assessed numerous variables to identify multiple risk factors in children with autism. Suicide ideation or attempts were more common in autistic males (15%) than females (7%); children with nonprofessional parents (16%), compared with those with professional parents (10%); black or Hispanic children (28%), compared with white or Asian children (13%); and in youths aged 10-16 years (32%), compared with those aged 1-9 years (10%).

Rates of suicide ideation or attempts increased with the number of risk factors, with rates of 11%-71% in children with two to four of these demographic risk factors (male sex, lower socioeconomic status, black or Hispanic race/ethnicity, and older age), Dr. Morgan reported.

Higher rates of suicide ideation or attempts also were seen in autistic children whose mothers reported that the child had been teased (19%) than in those who were not teased, in those who were depressed (26%), compared with nondepressed (5%), and in those with behavior problems (24%), compared with children without behavior problems (7%).

Rates of suicide ideation or attempts increased from 6% to 46% in autistic children with one to three of these comorbidity risk factors (teasing, depression, or behavior problems).

Screening for suicidality is especially important for children with these demographic and comorbidity risk factors, because the children’s risk might be reduced by interventions focused on teasing, mood, behavior problems, depression, and adversities related to race or socioeconomic status, Dr. Morgan said.

Factors that were not associated with suicide ideation and attempts in autistic children included IQ, the severity of autism, attention deficit, hyperactivity, psychosis, eating disturbances, or excessive sleep.

The study "reminds us that there’s the issue of ‘diagnostic overshadowing’ that can occur with patients – kids and adults – who are on the autism spectrum," she said. "We have to remember that these individuals also suffer from other disorders" and that symptoms of depression, suicidal ideation, and suicide behaviors should not be overlooked.

Because the study relied on parental reports, it provides a better understanding of how children with autism are perceived by their parents, but more research is needed to discern whether the children truly were considering and attempting to kill themselves or whether some of these were attempts by the autistic children to communicate something else.

"It’s important to screen more thoroughly when we have patients on the autism spectrum and make sure that we’re really understanding what’s going on with them," she said.

The investigators hope to expand their research to include other clinical sites, especially more urban sites, with a greater diversity of children.

Previous studies have shown depressed mood in 54% of children with high-functioning autism and 42% of children with low-functioning autism, she said. The current study appears to be the first to investigate suicidal ideation and attempts in autistic children.

Dr. Gorman reported having no financial disclosures.

[email protected]

On Twitter @sherryboschert

Suicide attempts or ideation were a problem in 43% of autistic children compared with 14% of depressed nonautistic children and 0.5% of children with neither depression nor autism, in a prospective study of 1,012 children.

Mothers of the children rated 165 items on the Pediatric Behavior Scale from "not at all a problem" to "very often a problem." Suicide ideation and attempts were considered a problem if they occurred anywhere from sometimes to very often.

"Because suicide ideation and attempts in autism are significantly higher than the norm, all children with autism should be screened for suicide ideation or attempts," Angela A. Gorman, Ph.D., said at a poster presentation at the annual meeting of the American Academy of Child and Adolescent Psychiatry.

Among the 179 autistic children, 77% of those with suicide ideation or attempts were depressed, but only 28% of those with depression had suicide ideation or attempts. Among autistic children without depression, 95% had no suicide ideation or attempts, reported Dr. Gorman, a clinical psychologist in the department of psychiatry at Pennsylvania State College of Medicine, Hershey, and her associates.

The autistic children ranged in age from 1 to 16 years; 68% had high-function autism (defined as an IQ of 80 or higher), and the rest had low-functioning autism. The 35 nonautistic children with depression ranged in age from 8 to 16 years, and the 186 typical children were 6-12 years old.

Males comprised 84% of the autistic group, 26% of the nonautistic depressed group, and 44% of the typical group. The proportions of parents whose occupations were professional or managerial (indicating higher socioeconomic status) were 37% in the autistic group, 51% in the nonautistic with depression, and 51% in the typical group. The study cohort came mainly from rural, central Pennsylvania, where white children made up 92% of the autistic group, 94% of the nonautistic with depression, and 78% of the typical group.

The study assessed numerous variables to identify multiple risk factors in children with autism. Suicide ideation or attempts were more common in autistic males (15%) than females (7%); children with nonprofessional parents (16%), compared with those with professional parents (10%); black or Hispanic children (28%), compared with white or Asian children (13%); and in youths aged 10-16 years (32%), compared with those aged 1-9 years (10%).

Rates of suicide ideation or attempts increased with the number of risk factors, with rates of 11%-71% in children with two to four of these demographic risk factors (male sex, lower socioeconomic status, black or Hispanic race/ethnicity, and older age), Dr. Morgan reported.

Higher rates of suicide ideation or attempts also were seen in autistic children whose mothers reported that the child had been teased (19%) than in those who were not teased, in those who were depressed (26%), compared with nondepressed (5%), and in those with behavior problems (24%), compared with children without behavior problems (7%).

Rates of suicide ideation or attempts increased from 6% to 46% in autistic children with one to three of these comorbidity risk factors (teasing, depression, or behavior problems).

Screening for suicidality is especially important for children with these demographic and comorbidity risk factors, because the children’s risk might be reduced by interventions focused on teasing, mood, behavior problems, depression, and adversities related to race or socioeconomic status, Dr. Morgan said.

Factors that were not associated with suicide ideation and attempts in autistic children included IQ, the severity of autism, attention deficit, hyperactivity, psychosis, eating disturbances, or excessive sleep.

The study "reminds us that there’s the issue of ‘diagnostic overshadowing’ that can occur with patients – kids and adults – who are on the autism spectrum," she said. "We have to remember that these individuals also suffer from other disorders" and that symptoms of depression, suicidal ideation, and suicide behaviors should not be overlooked.

Because the study relied on parental reports, it provides a better understanding of how children with autism are perceived by their parents, but more research is needed to discern whether the children truly were considering and attempting to kill themselves or whether some of these were attempts by the autistic children to communicate something else.

"It’s important to screen more thoroughly when we have patients on the autism spectrum and make sure that we’re really understanding what’s going on with them," she said.

The investigators hope to expand their research to include other clinical sites, especially more urban sites, with a greater diversity of children.

Previous studies have shown depressed mood in 54% of children with high-functioning autism and 42% of children with low-functioning autism, she said. The current study appears to be the first to investigate suicidal ideation and attempts in autistic children.

Dr. Gorman reported having no financial disclosures.

[email protected]

On Twitter @sherryboschert

Suicide attempts or ideation were a problem in 43% of autistic children compared with 14% of depressed nonautistic children and 0.5% of children with neither depression nor autism, in a prospective study of 1,012 children.

Mothers of the children rated 165 items on the Pediatric Behavior Scale from "not at all a problem" to "very often a problem." Suicide ideation and attempts were considered a problem if they occurred anywhere from sometimes to very often.

"Because suicide ideation and attempts in autism are significantly higher than the norm, all children with autism should be screened for suicide ideation or attempts," Angela A. Gorman, Ph.D., said at a poster presentation at the annual meeting of the American Academy of Child and Adolescent Psychiatry.

Among the 179 autistic children, 77% of those with suicide ideation or attempts were depressed, but only 28% of those with depression had suicide ideation or attempts. Among autistic children without depression, 95% had no suicide ideation or attempts, reported Dr. Gorman, a clinical psychologist in the department of psychiatry at Pennsylvania State College of Medicine, Hershey, and her associates.

The autistic children ranged in age from 1 to 16 years; 68% had high-function autism (defined as an IQ of 80 or higher), and the rest had low-functioning autism. The 35 nonautistic children with depression ranged in age from 8 to 16 years, and the 186 typical children were 6-12 years old.

Males comprised 84% of the autistic group, 26% of the nonautistic depressed group, and 44% of the typical group. The proportions of parents whose occupations were professional or managerial (indicating higher socioeconomic status) were 37% in the autistic group, 51% in the nonautistic with depression, and 51% in the typical group. The study cohort came mainly from rural, central Pennsylvania, where white children made up 92% of the autistic group, 94% of the nonautistic with depression, and 78% of the typical group.

The study assessed numerous variables to identify multiple risk factors in children with autism. Suicide ideation or attempts were more common in autistic males (15%) than females (7%); children with nonprofessional parents (16%), compared with those with professional parents (10%); black or Hispanic children (28%), compared with white or Asian children (13%); and in youths aged 10-16 years (32%), compared with those aged 1-9 years (10%).

Rates of suicide ideation or attempts increased with the number of risk factors, with rates of 11%-71% in children with two to four of these demographic risk factors (male sex, lower socioeconomic status, black or Hispanic race/ethnicity, and older age), Dr. Morgan reported.

Higher rates of suicide ideation or attempts also were seen in autistic children whose mothers reported that the child had been teased (19%) than in those who were not teased, in those who were depressed (26%), compared with nondepressed (5%), and in those with behavior problems (24%), compared with children without behavior problems (7%).

Rates of suicide ideation or attempts increased from 6% to 46% in autistic children with one to three of these comorbidity risk factors (teasing, depression, or behavior problems).

Screening for suicidality is especially important for children with these demographic and comorbidity risk factors, because the children’s risk might be reduced by interventions focused on teasing, mood, behavior problems, depression, and adversities related to race or socioeconomic status, Dr. Morgan said.

Factors that were not associated with suicide ideation and attempts in autistic children included IQ, the severity of autism, attention deficit, hyperactivity, psychosis, eating disturbances, or excessive sleep.

The study "reminds us that there’s the issue of ‘diagnostic overshadowing’ that can occur with patients – kids and adults – who are on the autism spectrum," she said. "We have to remember that these individuals also suffer from other disorders" and that symptoms of depression, suicidal ideation, and suicide behaviors should not be overlooked.

Because the study relied on parental reports, it provides a better understanding of how children with autism are perceived by their parents, but more research is needed to discern whether the children truly were considering and attempting to kill themselves or whether some of these were attempts by the autistic children to communicate something else.

"It’s important to screen more thoroughly when we have patients on the autism spectrum and make sure that we’re really understanding what’s going on with them," she said.

The investigators hope to expand their research to include other clinical sites, especially more urban sites, with a greater diversity of children.

Previous studies have shown depressed mood in 54% of children with high-functioning autism and 42% of children with low-functioning autism, she said. The current study appears to be the first to investigate suicidal ideation and attempts in autistic children.

Dr. Gorman reported having no financial disclosures.

[email protected]

On Twitter @sherryboschert

SAN FRANCISCO – Dr. Margaret D. Weiss had hoped that the group psychotherapy program she started for students with attention-deficit/hyperactivity disorder at the University of British Columbia might be more successful than some similar groups she’d heard about elsewhere with disappointing outcomes.

Her hopes were dashed, but some lessons were learned.

Despite a high rate of dropouts from the program, some students showed improvements. For other students, however, the group just confirmed their conviction that they were failures. In one group, for example, participants came to agreement in the very first session that they were all hopeless losers, and that psychiatrists and psychologists were stupid because they kept telling the students to do things that they had been trying to do for 20 years with little success.

©thinkstockphotos.com

The moral of that story is that "with college students, you have to do CBT [cognitive-behavioral therapy] first," she said at the annual meeting of the American Academy of Child and Adolescent Psychiatry. If the students don’t gain some confidence through hands-on CBT-like groups that teach executive function skills, group therapy is not going to work, said Dr. Weiss, head of the ADHD clinic at the university, in Vancouver.

Her program has made some adjustments that could improve chances for success, she said. In Canada, all college students with ADHD are entitled to accommodations and student disability services. However, now students at her institution will be told that in order to get the ADHD accommodations, they must take a required course of CBT and group therapy.

"It’s got to be on campus and scheduled so that they’ll come," and it must be highly structured, with an emphasis on praising the students’ efforts, not their achievements, she said.

Contact with other students who have ADHD might be especially important for college students with the disorder, Dr. Weiss said. Group psychotherapy can be very effective for lonely students. College students with ADHD who live away from home are more likely to have trouble managing activities of daily living, dealing with the distractions of dormitories and partying, falling behind academically and being unable to catch up, and negotiating the world of dating. They are at greater risk of loneliness, emotional dysregulation, self-medication, arguing with teachers, and becoming addicted to computers.

In one survey of 1,638 college students, 68 of whom had ADHD, the students with ADHD reported greater concerns about academic performance and depressive symptoms during the transition to college, Dr. Weiss said. Treatment with medication alone does not seem to diminish ADHD symptoms or improve student adjustment to college, multiple studies have shown. Programs that carry forward the skills-based training that children with ADHD receive are needed for college students to succeed.

"Pills do not build skills," she said.

Typically, children with ADHD are followed in pediatrics and psychiatry until they reach age 18 and then are "abandoned" at a key point in life when they face intense challenges – leaving home, learning to drive, and dealing with peer drug use, the complexities of dating, and the increased demand for executive function in college, Dr. Weiss said.

"Treatment in childhood does not mitigate adult outcomes without ongoing follow-up," she said. "Early intervention for ADHD is forever." College students with ADHD need to be engaged in treatment before they fail.

An estimated 2%-8% of college students have clinically significant levels of ADHD symptoms, studies have shown, and 25% of college students with disabilities are diagnosed with ADHD. There have been few studies of assessment methods, however, and nearly no controlled studies of psychopharmacological, psychosocial, or educational interventions, Dr. Weiss said. Good measures of outcomes have not been developed in these cases, but at least college students can self-report on whether they’re doing well, getting to class on time, and taking notes, for example.

Research also is needed not only on college students with ADHD who are struggling, but on the resiliency of young people with ADHD who make it to college, she added. Studies should investigate the competencies of students with ADHD who have achieved success against the odds.

"If you read the early longitudinal follow-up studies" of students with ADHD, "you wouldn’t think that anybody got to college," she noted. In the modern era of disability services and accommodations, longitudinal outcomes might change. In the future, all colleges and universities will recognize ADHD in their students, and multimodal, multidisciplinary treatment of ADHD in college will be the norm, Dr. Weiss predicted.

"One of the biggest handicaps to adulthood is not having a college education. If we can give these kids a college education, then we have done a great deal for their future as adults," she said. When students get to the point where they can specialize in their passion, ADHD becomes less of a handicap.

Dr. Weiss reported that she has had financial relationships with Eli Lilly, Purdue Pharma, Janssen Pharmaceuticals, and Shire.

SAN FRANCISCO – Dr. Margaret D. Weiss had hoped that the group psychotherapy program she started for students with attention-deficit/hyperactivity disorder at the University of British Columbia might be more successful than some similar groups she’d heard about elsewhere with disappointing outcomes.

Her hopes were dashed, but some lessons were learned.

Despite a high rate of dropouts from the program, some students showed improvements. For other students, however, the group just confirmed their conviction that they were failures. In one group, for example, participants came to agreement in the very first session that they were all hopeless losers, and that psychiatrists and psychologists were stupid because they kept telling the students to do things that they had been trying to do for 20 years with little success.

©thinkstockphotos.com

The moral of that story is that "with college students, you have to do CBT [cognitive-behavioral therapy] first," she said at the annual meeting of the American Academy of Child and Adolescent Psychiatry. If the students don’t gain some confidence through hands-on CBT-like groups that teach executive function skills, group therapy is not going to work, said Dr. Weiss, head of the ADHD clinic at the university, in Vancouver.

Her program has made some adjustments that could improve chances for success, she said. In Canada, all college students with ADHD are entitled to accommodations and student disability services. However, now students at her institution will be told that in order to get the ADHD accommodations, they must take a required course of CBT and group therapy.

"It’s got to be on campus and scheduled so that they’ll come," and it must be highly structured, with an emphasis on praising the students’ efforts, not their achievements, she said.

Contact with other students who have ADHD might be especially important for college students with the disorder, Dr. Weiss said. Group psychotherapy can be very effective for lonely students. College students with ADHD who live away from home are more likely to have trouble managing activities of daily living, dealing with the distractions of dormitories and partying, falling behind academically and being unable to catch up, and negotiating the world of dating. They are at greater risk of loneliness, emotional dysregulation, self-medication, arguing with teachers, and becoming addicted to computers.

In one survey of 1,638 college students, 68 of whom had ADHD, the students with ADHD reported greater concerns about academic performance and depressive symptoms during the transition to college, Dr. Weiss said. Treatment with medication alone does not seem to diminish ADHD symptoms or improve student adjustment to college, multiple studies have shown. Programs that carry forward the skills-based training that children with ADHD receive are needed for college students to succeed.

"Pills do not build skills," she said.

Typically, children with ADHD are followed in pediatrics and psychiatry until they reach age 18 and then are "abandoned" at a key point in life when they face intense challenges – leaving home, learning to drive, and dealing with peer drug use, the complexities of dating, and the increased demand for executive function in college, Dr. Weiss said.

"Treatment in childhood does not mitigate adult outcomes without ongoing follow-up," she said. "Early intervention for ADHD is forever." College students with ADHD need to be engaged in treatment before they fail.

An estimated 2%-8% of college students have clinically significant levels of ADHD symptoms, studies have shown, and 25% of college students with disabilities are diagnosed with ADHD. There have been few studies of assessment methods, however, and nearly no controlled studies of psychopharmacological, psychosocial, or educational interventions, Dr. Weiss said. Good measures of outcomes have not been developed in these cases, but at least college students can self-report on whether they’re doing well, getting to class on time, and taking notes, for example.

Research also is needed not only on college students with ADHD who are struggling, but on the resiliency of young people with ADHD who make it to college, she added. Studies should investigate the competencies of students with ADHD who have achieved success against the odds.

"If you read the early longitudinal follow-up studies" of students with ADHD, "you wouldn’t think that anybody got to college," she noted. In the modern era of disability services and accommodations, longitudinal outcomes might change. In the future, all colleges and universities will recognize ADHD in their students, and multimodal, multidisciplinary treatment of ADHD in college will be the norm, Dr. Weiss predicted.

"One of the biggest handicaps to adulthood is not having a college education. If we can give these kids a college education, then we have done a great deal for their future as adults," she said. When students get to the point where they can specialize in their passion, ADHD becomes less of a handicap.

Dr. Weiss reported that she has had financial relationships with Eli Lilly, Purdue Pharma, Janssen Pharmaceuticals, and Shire.

SAN FRANCISCO – Dr. Margaret D. Weiss had hoped that the group psychotherapy program she started for students with attention-deficit/hyperactivity disorder at the University of British Columbia might be more successful than some similar groups she’d heard about elsewhere with disappointing outcomes.

Her hopes were dashed, but some lessons were learned.

Despite a high rate of dropouts from the program, some students showed improvements. For other students, however, the group just confirmed their conviction that they were failures. In one group, for example, participants came to agreement in the very first session that they were all hopeless losers, and that psychiatrists and psychologists were stupid because they kept telling the students to do things that they had been trying to do for 20 years with little success.

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The moral of that story is that "with college students, you have to do CBT [cognitive-behavioral therapy] first," she said at the annual meeting of the American Academy of Child and Adolescent Psychiatry. If the students don’t gain some confidence through hands-on CBT-like groups that teach executive function skills, group therapy is not going to work, said Dr. Weiss, head of the ADHD clinic at the university, in Vancouver.

Her program has made some adjustments that could improve chances for success, she said. In Canada, all college students with ADHD are entitled to accommodations and student disability services. However, now students at her institution will be told that in order to get the ADHD accommodations, they must take a required course of CBT and group therapy.

"It’s got to be on campus and scheduled so that they’ll come," and it must be highly structured, with an emphasis on praising the students’ efforts, not their achievements, she said.

Contact with other students who have ADHD might be especially important for college students with the disorder, Dr. Weiss said. Group psychotherapy can be very effective for lonely students. College students with ADHD who live away from home are more likely to have trouble managing activities of daily living, dealing with the distractions of dormitories and partying, falling behind academically and being unable to catch up, and negotiating the world of dating. They are at greater risk of loneliness, emotional dysregulation, self-medication, arguing with teachers, and becoming addicted to computers.

In one survey of 1,638 college students, 68 of whom had ADHD, the students with ADHD reported greater concerns about academic performance and depressive symptoms during the transition to college, Dr. Weiss said. Treatment with medication alone does not seem to diminish ADHD symptoms or improve student adjustment to college, multiple studies have shown. Programs that carry forward the skills-based training that children with ADHD receive are needed for college students to succeed.

"Pills do not build skills," she said.

Typically, children with ADHD are followed in pediatrics and psychiatry until they reach age 18 and then are "abandoned" at a key point in life when they face intense challenges – leaving home, learning to drive, and dealing with peer drug use, the complexities of dating, and the increased demand for executive function in college, Dr. Weiss said.

"Treatment in childhood does not mitigate adult outcomes without ongoing follow-up," she said. "Early intervention for ADHD is forever." College students with ADHD need to be engaged in treatment before they fail.

An estimated 2%-8% of college students have clinically significant levels of ADHD symptoms, studies have shown, and 25% of college students with disabilities are diagnosed with ADHD. There have been few studies of assessment methods, however, and nearly no controlled studies of psychopharmacological, psychosocial, or educational interventions, Dr. Weiss said. Good measures of outcomes have not been developed in these cases, but at least college students can self-report on whether they’re doing well, getting to class on time, and taking notes, for example.

Research also is needed not only on college students with ADHD who are struggling, but on the resiliency of young people with ADHD who make it to college, she added. Studies should investigate the competencies of students with ADHD who have achieved success against the odds.

"If you read the early longitudinal follow-up studies" of students with ADHD, "you wouldn’t think that anybody got to college," she noted. In the modern era of disability services and accommodations, longitudinal outcomes might change. In the future, all colleges and universities will recognize ADHD in their students, and multimodal, multidisciplinary treatment of ADHD in college will be the norm, Dr. Weiss predicted.

"One of the biggest handicaps to adulthood is not having a college education. If we can give these kids a college education, then we have done a great deal for their future as adults," she said. When students get to the point where they can specialize in their passion, ADHD becomes less of a handicap.

Dr. Weiss reported that she has had financial relationships with Eli Lilly, Purdue Pharma, Janssen Pharmaceuticals, and Shire.

SAN FRANCISCO – Seven percent of 110 children with autism spectrum disorders had iron depletion before starting antipsychotics for aggression, and rapid weight gain on antipsychotics was associated with further decreases in iron levels.

Eleven percent of 79 children with follow-up data after a mean of 18 months of antipsychotic treatment had low plasma ferritin levels (less than 12 ng/mL). Mean plasma ferritin concentrations in the cohort as a whole decreased from 26 ng/mL at baseline to 17 ng/mL, Dr. Nicole S. Del Castillo reported in a poster presentation at the annual meeting of the American Academy of Child and Adolescent Psychiatry.

The mean body mass index (BMI) was 18 kg/m² at baseline and 20 kg/m² after 18 months. The percent increase in BMI was significantly and negatively associated with the decrease in ferritin concentration, change in ferritin, and percent change in ferritin after adjustment for the effects of other factors, reported Dr. Del Castillo, a psychiatry fellow at the University of Iowa, Iowa City.

The investigators adjusted for the effects of age, sex, and the time between baseline and follow-up BMI measurements.

Children with autism spectrum disorders already are at increased risk of iron deficiency, previous studies have shown. Other studies report that two second-generation antipsychotics that are approved to treat aggression associated with autism spectrum disorders – risperidone and aripiprazole – cause significant weight gain, especially in youth. Rapid weight gain can lead to iron deficiency in children when iron absorption is unable to keep pace with the need to form red blood cells to vascularize newly formed tissue, Dr. Del Castillo explained.

Clinicians should consider closely monitoring iron status in children with autism spectrum disorders who are treated with second-generation antipsychotics, especially if they gain substantial weight, she suggested. "Not only test for lipids and glucose, but also look at iron deficiency," which is a potentially treatable problem, she said.

The study analyzed data obtained from a Research Units on Pediatric Psychopharmacology trial in which children with autism spectrum disorders and serious behavior problems were randomized to treatment with risperidone alone or risperidone plus behavior management training for parents. Patients in the current sample averaged 8 years in age. Primary diagnoses included autism in 62%, pervasive developmental disorder not otherwise specified in 32%, and Asperger’s syndrome in 6%.

No significant associations were seen between baseline ferritin concentrations and age, baseline BMI, baseline or follow-up scores on the Aberrant Behavior Checklist, or percent change in ferritin concentration.

Dr. Del Castillo reported having no relevant financial disclosures. Some of her coinvestigators reported relationships with several pharmaceutical companies, including , Eli Lilly, Shire, AstraZeneca, Novartis, Forest Research, and Hoffmann-LaRoche.

SAN FRANCISCO – Seven percent of 110 children with autism spectrum disorders had iron depletion before starting antipsychotics for aggression, and rapid weight gain on antipsychotics was associated with further decreases in iron levels.

Eleven percent of 79 children with follow-up data after a mean of 18 months of antipsychotic treatment had low plasma ferritin levels (less than 12 ng/mL). Mean plasma ferritin concentrations in the cohort as a whole decreased from 26 ng/mL at baseline to 17 ng/mL, Dr. Nicole S. Del Castillo reported in a poster presentation at the annual meeting of the American Academy of Child and Adolescent Psychiatry.

The mean body mass index (BMI) was 18 kg/m² at baseline and 20 kg/m² after 18 months. The percent increase in BMI was significantly and negatively associated with the decrease in ferritin concentration, change in ferritin, and percent change in ferritin after adjustment for the effects of other factors, reported Dr. Del Castillo, a psychiatry fellow at the University of Iowa, Iowa City.

The investigators adjusted for the effects of age, sex, and the time between baseline and follow-up BMI measurements.

Children with autism spectrum disorders already are at increased risk of iron deficiency, previous studies have shown. Other studies report that two second-generation antipsychotics that are approved to treat aggression associated with autism spectrum disorders – risperidone and aripiprazole – cause significant weight gain, especially in youth. Rapid weight gain can lead to iron deficiency in children when iron absorption is unable to keep pace with the need to form red blood cells to vascularize newly formed tissue, Dr. Del Castillo explained.

Clinicians should consider closely monitoring iron status in children with autism spectrum disorders who are treated with second-generation antipsychotics, especially if they gain substantial weight, she suggested. "Not only test for lipids and glucose, but also look at iron deficiency," which is a potentially treatable problem, she said.

The study analyzed data obtained from a Research Units on Pediatric Psychopharmacology trial in which children with autism spectrum disorders and serious behavior problems were randomized to treatment with risperidone alone or risperidone plus behavior management training for parents. Patients in the current sample averaged 8 years in age. Primary diagnoses included autism in 62%, pervasive developmental disorder not otherwise specified in 32%, and Asperger’s syndrome in 6%.

No significant associations were seen between baseline ferritin concentrations and age, baseline BMI, baseline or follow-up scores on the Aberrant Behavior Checklist, or percent change in ferritin concentration.

Dr. Del Castillo reported having no relevant financial disclosures. Some of her coinvestigators reported relationships with several pharmaceutical companies, including , Eli Lilly, Shire, AstraZeneca, Novartis, Forest Research, and Hoffmann-LaRoche.

SAN FRANCISCO – Seven percent of 110 children with autism spectrum disorders had iron depletion before starting antipsychotics for aggression, and rapid weight gain on antipsychotics was associated with further decreases in iron levels.

Eleven percent of 79 children with follow-up data after a mean of 18 months of antipsychotic treatment had low plasma ferritin levels (less than 12 ng/mL). Mean plasma ferritin concentrations in the cohort as a whole decreased from 26 ng/mL at baseline to 17 ng/mL, Dr. Nicole S. Del Castillo reported in a poster presentation at the annual meeting of the American Academy of Child and Adolescent Psychiatry.

The mean body mass index (BMI) was 18 kg/m² at baseline and 20 kg/m² after 18 months. The percent increase in BMI was significantly and negatively associated with the decrease in ferritin concentration, change in ferritin, and percent change in ferritin after adjustment for the effects of other factors, reported Dr. Del Castillo, a psychiatry fellow at the University of Iowa, Iowa City.

The investigators adjusted for the effects of age, sex, and the time between baseline and follow-up BMI measurements.

Children with autism spectrum disorders already are at increased risk of iron deficiency, previous studies have shown. Other studies report that two second-generation antipsychotics that are approved to treat aggression associated with autism spectrum disorders – risperidone and aripiprazole – cause significant weight gain, especially in youth. Rapid weight gain can lead to iron deficiency in children when iron absorption is unable to keep pace with the need to form red blood cells to vascularize newly formed tissue, Dr. Del Castillo explained.

Clinicians should consider closely monitoring iron status in children with autism spectrum disorders who are treated with second-generation antipsychotics, especially if they gain substantial weight, she suggested. "Not only test for lipids and glucose, but also look at iron deficiency," which is a potentially treatable problem, she said.

The study analyzed data obtained from a Research Units on Pediatric Psychopharmacology trial in which children with autism spectrum disorders and serious behavior problems were randomized to treatment with risperidone alone or risperidone plus behavior management training for parents. Patients in the current sample averaged 8 years in age. Primary diagnoses included autism in 62%, pervasive developmental disorder not otherwise specified in 32%, and Asperger’s syndrome in 6%.

No significant associations were seen between baseline ferritin concentrations and age, baseline BMI, baseline or follow-up scores on the Aberrant Behavior Checklist, or percent change in ferritin concentration.

Dr. Del Castillo reported having no relevant financial disclosures. Some of her coinvestigators reported relationships with several pharmaceutical companies, including , Eli Lilly, Shire, AstraZeneca, Novartis, Forest Research, and Hoffmann-LaRoche.

SAN FRANCISCO – Hispanic children with autism were nearly twice as likely to have a learning disability or speech problem compared with their peers in an analysis of data on 913 children with autism spectrum disorders.

The presence of these co-occurring conditions might help explain why Hispanic children are diagnosed with autism at lower rates and at older ages compared with white non-Hispanic children, Stephanie E. Bean hypothesized.

The higher rate of diagnosed "speech problems" in Hispanic children is not surprising, since many Hispanic households speak more than one language at home, she said in a poster presentation and interview at the annual meeting of the American Academy of Child and Adolescent Psychiatry.

"Because language delay is a factor of autism, it might be that the speech problem masks the autism spectrum disorder diagnosis," said Ms. Bean, a graduate student in public health at Johns Hopkins University, Baltimore.

The researchers adjusted for the effects of parental education and socioeconomic status.

Ms. Bean and her associates analyzed data from a subset of the National Survey of Children's Health drawn from phone interviews with parents of children aged 3-17 years who had a current autism spectrum disorder diagnosis. Average age was 10 years, and 10% were Hispanic.

Previous data from the Autism and Developmental Disabilities Monitoring Network suggest that the U.S. prevalence of autism spectrum disorders in 2008 was 12 per 1,000 in non-Hispanic white children, 10 per 1,000 in non-Hispanic blacks, and 8 per 1,000 in Hispanics (MMWR 2012;61[SS03]:1-19). A separate study of Medicaid records of children with autism showed that African American children were diagnosed 18 months later than were white children, on average, and Hispanic children received diagnoses even later (J. Am. Acad. Child. Adolesc. Psychiatry 2002;41:1447-53).

Another report suggested that psychiatric and neurodevelopmental conditions co-occurring with autism might lead to diagnostic misclassification and delay some children with autism spectrum disorders from receiving the early interventions that produce the greatest improvements, Ms. Bean said (Pediatrics 2012 Jan. 23 [doi:10.1542/peds.2011-1717]).

In the current study, anxiety disorders were 78% less likely in the 7% of children who were African American, compared with the 82% of white children. (Hispanics can be of any race.) This is in line with a previous study showing lower rates of anxiety diagnoses in African American children, she noted (J. Am. Acad. Child Adolesc. Psychiatry 1995;34:67-72).

No significant associations were found between race/ethnicity and other problems that commonly co-occur with autism, including attention-deficit/hyperactivity disorder, developmental delays, depression, behavior or conduct problems, epilepsy or seizure disorders, or hearing problems.

Learning disability was the most common co-occurring condition in the cohort as a whole, affecting 75% of children, and 87% of the children had an individualized education program. Mothers were the survey respondents in 79% of cases, and 74% of parents had achieved more than a high school diploma. Parents reported that 48% had family incomes greater than 300% of the federal poverty level, that 96% of children were insured at the time of the survey, and that 95% had been insured consistently over the prior year.

Ms. Bean reported having no financial disclosures.

SAN FRANCISCO – Hispanic children with autism were nearly twice as likely to have a learning disability or speech problem compared with their peers in an analysis of data on 913 children with autism spectrum disorders.

The presence of these co-occurring conditions might help explain why Hispanic children are diagnosed with autism at lower rates and at older ages compared with white non-Hispanic children, Stephanie E. Bean hypothesized.

The higher rate of diagnosed "speech problems" in Hispanic children is not surprising, since many Hispanic households speak more than one language at home, she said in a poster presentation and interview at the annual meeting of the American Academy of Child and Adolescent Psychiatry.

"Because language delay is a factor of autism, it might be that the speech problem masks the autism spectrum disorder diagnosis," said Ms. Bean, a graduate student in public health at Johns Hopkins University, Baltimore.

The researchers adjusted for the effects of parental education and socioeconomic status.

Ms. Bean and her associates analyzed data from a subset of the National Survey of Children's Health drawn from phone interviews with parents of children aged 3-17 years who had a current autism spectrum disorder diagnosis. Average age was 10 years, and 10% were Hispanic.

Previous data from the Autism and Developmental Disabilities Monitoring Network suggest that the U.S. prevalence of autism spectrum disorders in 2008 was 12 per 1,000 in non-Hispanic white children, 10 per 1,000 in non-Hispanic blacks, and 8 per 1,000 in Hispanics (MMWR 2012;61[SS03]:1-19). A separate study of Medicaid records of children with autism showed that African American children were diagnosed 18 months later than were white children, on average, and Hispanic children received diagnoses even later (J. Am. Acad. Child. Adolesc. Psychiatry 2002;41:1447-53).

Another report suggested that psychiatric and neurodevelopmental conditions co-occurring with autism might lead to diagnostic misclassification and delay some children with autism spectrum disorders from receiving the early interventions that produce the greatest improvements, Ms. Bean said (Pediatrics 2012 Jan. 23 [doi:10.1542/peds.2011-1717]).

In the current study, anxiety disorders were 78% less likely in the 7% of children who were African American, compared with the 82% of white children. (Hispanics can be of any race.) This is in line with a previous study showing lower rates of anxiety diagnoses in African American children, she noted (J. Am. Acad. Child Adolesc. Psychiatry 1995;34:67-72).

No significant associations were found between race/ethnicity and other problems that commonly co-occur with autism, including attention-deficit/hyperactivity disorder, developmental delays, depression, behavior or conduct problems, epilepsy or seizure disorders, or hearing problems.

Learning disability was the most common co-occurring condition in the cohort as a whole, affecting 75% of children, and 87% of the children had an individualized education program. Mothers were the survey respondents in 79% of cases, and 74% of parents had achieved more than a high school diploma. Parents reported that 48% had family incomes greater than 300% of the federal poverty level, that 96% of children were insured at the time of the survey, and that 95% had been insured consistently over the prior year.

Ms. Bean reported having no financial disclosures.

SAN FRANCISCO – Hispanic children with autism were nearly twice as likely to have a learning disability or speech problem compared with their peers in an analysis of data on 913 children with autism spectrum disorders.

The presence of these co-occurring conditions might help explain why Hispanic children are diagnosed with autism at lower rates and at older ages compared with white non-Hispanic children, Stephanie E. Bean hypothesized.

The higher rate of diagnosed "speech problems" in Hispanic children is not surprising, since many Hispanic households speak more than one language at home, she said in a poster presentation and interview at the annual meeting of the American Academy of Child and Adolescent Psychiatry.

"Because language delay is a factor of autism, it might be that the speech problem masks the autism spectrum disorder diagnosis," said Ms. Bean, a graduate student in public health at Johns Hopkins University, Baltimore.

The researchers adjusted for the effects of parental education and socioeconomic status.

Ms. Bean and her associates analyzed data from a subset of the National Survey of Children's Health drawn from phone interviews with parents of children aged 3-17 years who had a current autism spectrum disorder diagnosis. Average age was 10 years, and 10% were Hispanic.

Previous data from the Autism and Developmental Disabilities Monitoring Network suggest that the U.S. prevalence of autism spectrum disorders in 2008 was 12 per 1,000 in non-Hispanic white children, 10 per 1,000 in non-Hispanic blacks, and 8 per 1,000 in Hispanics (MMWR 2012;61[SS03]:1-19). A separate study of Medicaid records of children with autism showed that African American children were diagnosed 18 months later than were white children, on average, and Hispanic children received diagnoses even later (J. Am. Acad. Child. Adolesc. Psychiatry 2002;41:1447-53).

Another report suggested that psychiatric and neurodevelopmental conditions co-occurring with autism might lead to diagnostic misclassification and delay some children with autism spectrum disorders from receiving the early interventions that produce the greatest improvements, Ms. Bean said (Pediatrics 2012 Jan. 23 [doi:10.1542/peds.2011-1717]).

In the current study, anxiety disorders were 78% less likely in the 7% of children who were African American, compared with the 82% of white children. (Hispanics can be of any race.) This is in line with a previous study showing lower rates of anxiety diagnoses in African American children, she noted (J. Am. Acad. Child Adolesc. Psychiatry 1995;34:67-72).

No significant associations were found between race/ethnicity and other problems that commonly co-occur with autism, including attention-deficit/hyperactivity disorder, developmental delays, depression, behavior or conduct problems, epilepsy or seizure disorders, or hearing problems.

Learning disability was the most common co-occurring condition in the cohort as a whole, affecting 75% of children, and 87% of the children had an individualized education program. Mothers were the survey respondents in 79% of cases, and 74% of parents had achieved more than a high school diploma. Parents reported that 48% had family incomes greater than 300% of the federal poverty level, that 96% of children were insured at the time of the survey, and that 95% had been insured consistently over the prior year.

Ms. Bean reported having no financial disclosures.

SAN FRANCISCO – Attention-retraining therapy works in adolescents with anxiety disorders, the first randomized, controlled trial in this age group has found.

Previous studies of attention-retraining therapy all focused on adults. In this study of 42 adolescents with severe anxiety in a residential treatment program, standard treatment with 25 hours/week of cognitive-behavioral therapy (CBT) significantly improved symptom scores in a control group that got CBT plus a computerized placebo, but scores improved even more in patients randomized to CBT plus computerized attention-retraining therapy.

Scores improved on a broad measure of pediatric anxiety, the SCARED (Self-Report for Child Anxiety Related Emotional Disorder) checklist, from an average of 32 at admission to 21 at discharge in the CBT group and from 34 to 12 in the combination group, Bradley C. Riemann, Ph.D., and his associates reported at the annual meeting of the American Academy of Child and Adolescent Psychiatry.

Most patients in each group had a primary diagnosis of obsessive-compulsive disorder (OCD): 17 patients in the control group and 13 in the combination group. Scores improved on the CYBOCS-SR (Children’s Yale-Brown Obsessive Compulsive Scale–Self-Report) symptom checklist from 25 at admission to 12 at discharge in the CBT group and from 26 to 7 in the combination group, reported Dr. Riemann of Rogers Memorial Hospital, Oconomowoc, Wisc.

"What you see is enhancement effects," he said.

In more clinical terms, the CBT group went from scores in the severe range to the mild range. "So, CBT works," he said. In the combination group, patient scores went from the severe range to the "essentially subclinical" range.

This was a complex patient group with high levels of comorbidity and life disruption. Primary diagnoses included OCD, social anxiety disorder, generalized anxiety disorder, panic disorder, and anxiety disorder not otherwise specified. Comorbidities included major depression in a large proportion of patients, attention-deficit/hyperactivity disorder (ADHD), or eating disorders. Characteristics did not differ significantly between groups.

Patients averaged 15-16 years of age and stayed an average of 60-62 days in the residential program.

The attention-retraining group was asked to do the computerized therapy each weekday during "school" time, and patients ended up doing it about 3.5 days/week on average, he said.

The computer exercises presented a screen with a neutral face and a face showing disgust, followed by a screen with no faces but a "probe" where one of the faces had been (such as the letter E indicating that the patient should respond with a left-click of the mouse or the letter F indicating a right click for response). In the attention-retraining group, the probe always followed the neutral face. In the control group, the probe appeared 50% of the time behind each face.

"We weren’t targeting OCD, but keep in mind that there is an area of disgust that you see in OCD. Maybe this was hitting that target as well," Dr. Riemann said.

The attention retraining also seemed to have generalized effects in small subgroups with comorbid ADHD. The six patients with ADHD in the control group showed less improvement in their anxiety than control patients without ADHD, suggesting that the ADHD was interfering with the CBT. But in the combination therapy group, gains were not attenuated in the four patients with comorbid ADHD. The numbers are too small to make too much of this but suggest that perhaps attention-retraining therapy "may be something that could be applied to that even more complicated population" with anxiety and ADHD, he said.

The attention retraining is based on previous research showing that anxious individuals consistently focus their attention where they perceive potential threats, including a meta-analysis of 172 studies (Psychol. Bull. 2007;133:1-24).

At least two studies of single sessions of computerized attention retraining and three studies of multiple treatment sessions in adults have shown significant reductions in anxiety after treatment. The adult multiple-session studies typically involved twice-weekly sessions for 4 weeks, less frequent than in the adolescent trial.

Dr. Riemann reported having no financial disclosures.

SAN FRANCISCO – Attention-retraining therapy works in adolescents with anxiety disorders, the first randomized, controlled trial in this age group has found.

Previous studies of attention-retraining therapy all focused on adults. In this study of 42 adolescents with severe anxiety in a residential treatment program, standard treatment with 25 hours/week of cognitive-behavioral therapy (CBT) significantly improved symptom scores in a control group that got CBT plus a computerized placebo, but scores improved even more in patients randomized to CBT plus computerized attention-retraining therapy.

Scores improved on a broad measure of pediatric anxiety, the SCARED (Self-Report for Child Anxiety Related Emotional Disorder) checklist, from an average of 32 at admission to 21 at discharge in the CBT group and from 34 to 12 in the combination group, Bradley C. Riemann, Ph.D., and his associates reported at the annual meeting of the American Academy of Child and Adolescent Psychiatry.

Most patients in each group had a primary diagnosis of obsessive-compulsive disorder (OCD): 17 patients in the control group and 13 in the combination group. Scores improved on the CYBOCS-SR (Children’s Yale-Brown Obsessive Compulsive Scale–Self-Report) symptom checklist from 25 at admission to 12 at discharge in the CBT group and from 26 to 7 in the combination group, reported Dr. Riemann of Rogers Memorial Hospital, Oconomowoc, Wisc.

"What you see is enhancement effects," he said.

In more clinical terms, the CBT group went from scores in the severe range to the mild range. "So, CBT works," he said. In the combination group, patient scores went from the severe range to the "essentially subclinical" range.

This was a complex patient group with high levels of comorbidity and life disruption. Primary diagnoses included OCD, social anxiety disorder, generalized anxiety disorder, panic disorder, and anxiety disorder not otherwise specified. Comorbidities included major depression in a large proportion of patients, attention-deficit/hyperactivity disorder (ADHD), or eating disorders. Characteristics did not differ significantly between groups.

Patients averaged 15-16 years of age and stayed an average of 60-62 days in the residential program.

The attention-retraining group was asked to do the computerized therapy each weekday during "school" time, and patients ended up doing it about 3.5 days/week on average, he said.

The computer exercises presented a screen with a neutral face and a face showing disgust, followed by a screen with no faces but a "probe" where one of the faces had been (such as the letter E indicating that the patient should respond with a left-click of the mouse or the letter F indicating a right click for response). In the attention-retraining group, the probe always followed the neutral face. In the control group, the probe appeared 50% of the time behind each face.

"We weren’t targeting OCD, but keep in mind that there is an area of disgust that you see in OCD. Maybe this was hitting that target as well," Dr. Riemann said.

The attention retraining also seemed to have generalized effects in small subgroups with comorbid ADHD. The six patients with ADHD in the control group showed less improvement in their anxiety than control patients without ADHD, suggesting that the ADHD was interfering with the CBT. But in the combination therapy group, gains were not attenuated in the four patients with comorbid ADHD. The numbers are too small to make too much of this but suggest that perhaps attention-retraining therapy "may be something that could be applied to that even more complicated population" with anxiety and ADHD, he said.

The attention retraining is based on previous research showing that anxious individuals consistently focus their attention where they perceive potential threats, including a meta-analysis of 172 studies (Psychol. Bull. 2007;133:1-24).

At least two studies of single sessions of computerized attention retraining and three studies of multiple treatment sessions in adults have shown significant reductions in anxiety after treatment. The adult multiple-session studies typically involved twice-weekly sessions for 4 weeks, less frequent than in the adolescent trial.

Dr. Riemann reported having no financial disclosures.

SAN FRANCISCO – Attention-retraining therapy works in adolescents with anxiety disorders, the first randomized, controlled trial in this age group has found.

Previous studies of attention-retraining therapy all focused on adults. In this study of 42 adolescents with severe anxiety in a residential treatment program, standard treatment with 25 hours/week of cognitive-behavioral therapy (CBT) significantly improved symptom scores in a control group that got CBT plus a computerized placebo, but scores improved even more in patients randomized to CBT plus computerized attention-retraining therapy.

Scores improved on a broad measure of pediatric anxiety, the SCARED (Self-Report for Child Anxiety Related Emotional Disorder) checklist, from an average of 32 at admission to 21 at discharge in the CBT group and from 34 to 12 in the combination group, Bradley C. Riemann, Ph.D., and his associates reported at the annual meeting of the American Academy of Child and Adolescent Psychiatry.

Most patients in each group had a primary diagnosis of obsessive-compulsive disorder (OCD): 17 patients in the control group and 13 in the combination group. Scores improved on the CYBOCS-SR (Children’s Yale-Brown Obsessive Compulsive Scale–Self-Report) symptom checklist from 25 at admission to 12 at discharge in the CBT group and from 26 to 7 in the combination group, reported Dr. Riemann of Rogers Memorial Hospital, Oconomowoc, Wisc.

"What you see is enhancement effects," he said.

In more clinical terms, the CBT group went from scores in the severe range to the mild range. "So, CBT works," he said. In the combination group, patient scores went from the severe range to the "essentially subclinical" range.

This was a complex patient group with high levels of comorbidity and life disruption. Primary diagnoses included OCD, social anxiety disorder, generalized anxiety disorder, panic disorder, and anxiety disorder not otherwise specified. Comorbidities included major depression in a large proportion of patients, attention-deficit/hyperactivity disorder (ADHD), or eating disorders. Characteristics did not differ significantly between groups.

Patients averaged 15-16 years of age and stayed an average of 60-62 days in the residential program.

The attention-retraining group was asked to do the computerized therapy each weekday during "school" time, and patients ended up doing it about 3.5 days/week on average, he said.

The computer exercises presented a screen with a neutral face and a face showing disgust, followed by a screen with no faces but a "probe" where one of the faces had been (such as the letter E indicating that the patient should respond with a left-click of the mouse or the letter F indicating a right click for response). In the attention-retraining group, the probe always followed the neutral face. In the control group, the probe appeared 50% of the time behind each face.

"We weren’t targeting OCD, but keep in mind that there is an area of disgust that you see in OCD. Maybe this was hitting that target as well," Dr. Riemann said.

The attention retraining also seemed to have generalized effects in small subgroups with comorbid ADHD. The six patients with ADHD in the control group showed less improvement in their anxiety than control patients without ADHD, suggesting that the ADHD was interfering with the CBT. But in the combination therapy group, gains were not attenuated in the four patients with comorbid ADHD. The numbers are too small to make too much of this but suggest that perhaps attention-retraining therapy "may be something that could be applied to that even more complicated population" with anxiety and ADHD, he said.

The attention retraining is based on previous research showing that anxious individuals consistently focus their attention where they perceive potential threats, including a meta-analysis of 172 studies (Psychol. Bull. 2007;133:1-24).

At least two studies of single sessions of computerized attention retraining and three studies of multiple treatment sessions in adults have shown significant reductions in anxiety after treatment. The adult multiple-session studies typically involved twice-weekly sessions for 4 weeks, less frequent than in the adolescent trial.

Dr. Riemann reported having no financial disclosures.

SAN FRANCISCO – An innovative family-focused treatment program for complex cases of pediatric obsessive-compulsive disorder that looked promising in a randomized, controlled pilot trial of 20 families has now accumulated experience with 35 families.

"We’re getting increasingly confident that we may have something here," Tara S. Peris, Ph.D., said at the annual meeting of the American Academy of Child and Adolescent Psychiatry.

A larger study is being planned of the adjunctive positive family interaction therapy (PFIT), which families in the prospective pilot study seemed to embrace. The study recruited families based on a primary diagnosis of pediatric obsessive-compulsive disorder (OCD) and an assessment of poor family functioning, and then randomized them to receive six sessions of standard therapy with individual child cognitive-behavioral therapy (CBT) or to standard therapy plus PFIT.

Seven of 10 patients in the PFIT group and 4 of 10 in the control group responded after six treatment sessions, as assessed on the Clinical Global Impressions of Improvement (CGI-I) scale by blinded raters. The 40% response rate in the control group "parallels what’s in other studies," noted Dr. Peris of the Semel Institute for Neuroscience and Human Behavior at the University of California, Los Angeles.

On the Children’s Yale–Brown Obsessive Compulsive Scale (CY-BOCS) of symptom severity, 5 of 10 patients in the PFIT group achieved remission, compared with 2 of 10 in the control group, reported Dr. Peris and her colleague at the institute, John Piacentini, Ph.D. (J. Clin. Child. Adolesc. Psychol. 2012 [doi: 10.1080/15374416.2012.673162]).

No families dropped out of the study, and 16 of the 20 families completed 3 months of follow-up. Youths in both groups maintained any gains at the 3-month follow-up. In the PFIT group, mothers and fathers attended 95% of the family therapy sessions together, and among PFIT families with siblings of the youth with OCD, 6 brought a sibling to at least one session.

CBT alone is the front-line treatment for mild to moderate pediatric OCD, "but we’re not here to talk about those kids," Dr. Peris said. Previous studies have shown that 46%-79% of youths with OCD fail treatment with CBT, medication, or a combination of the two, depending on the treatment.

The study targeted treatment-resistant patients who also had dysfunctional families, which previous data identified as a predictor of poor response to CBT treatment for OCD.

Dr. Peris and her associates earlier identified three characteristics of dysfunctional families that interfere with a family’s ability to stop accommodating OCD symptoms: blame, family conflict, and poor family cohesion. These factors have an additive effect: only 14% of youths in families with all three factors responded to CBT, compared with 93% in families with none of these characteristics, Dr. Peris reported (J. Consult. Clin. Psychol. 2012;80:255-63).

"These features argue for some degree of family intervention in pediatric OCD treatment," she said.

PFIT aims to reduce hostility and blame, increase family cohesion, and reduce OCD accommodation to enhance the efficacy of exposure-based CBT. "None of this is meant to blame parents or families. They’re doing their best. We try to give them better ways to cope," she said.

Previous family interventions tended to rely on psychoeducation, with limited success in changing family dynamics, she noted. PFIT provides psychoeducation but also focuses on increasing parental self-efficacy (the sense that one is able to produce and regulate events in one’s life), providing parents with skills training in emotion regulation (including calm disengagement from challenging OCD episodes), and improving parenting skills such as scaffolding (recognizing the level of skill the child has mastered, and thinking of one level beyond that).

PFIT also addresses broader family dynamics, including reducing criticism, promoting positive problem-solving as a family, increasing cohesion, and creating a common language for communicating about OCD symptoms.

In the study, mothers in the PFIT group reported significantly lower levels of blame at week 24, compared with mothers in the control group. The PFIT families showed significant decreases in accommodation, blame, and family conflict, Dr. Peris reported.

"PFIT may be a better strategy than standard CBT for complex cases of OCD," she said.

Dr. Peris reported having no financial disclosures.

SAN FRANCISCO – An innovative family-focused treatment program for complex cases of pediatric obsessive-compulsive disorder that looked promising in a randomized, controlled pilot trial of 20 families has now accumulated experience with 35 families.

"We’re getting increasingly confident that we may have something here," Tara S. Peris, Ph.D., said at the annual meeting of the American Academy of Child and Adolescent Psychiatry.

A larger study is being planned of the adjunctive positive family interaction therapy (PFIT), which families in the prospective pilot study seemed to embrace. The study recruited families based on a primary diagnosis of pediatric obsessive-compulsive disorder (OCD) and an assessment of poor family functioning, and then randomized them to receive six sessions of standard therapy with individual child cognitive-behavioral therapy (CBT) or to standard therapy plus PFIT.

Seven of 10 patients in the PFIT group and 4 of 10 in the control group responded after six treatment sessions, as assessed on the Clinical Global Impressions of Improvement (CGI-I) scale by blinded raters. The 40% response rate in the control group "parallels what’s in other studies," noted Dr. Peris of the Semel Institute for Neuroscience and Human Behavior at the University of California, Los Angeles.

On the Children’s Yale–Brown Obsessive Compulsive Scale (CY-BOCS) of symptom severity, 5 of 10 patients in the PFIT group achieved remission, compared with 2 of 10 in the control group, reported Dr. Peris and her colleague at the institute, John Piacentini, Ph.D. (J. Clin. Child. Adolesc. Psychol. 2012 [doi: 10.1080/15374416.2012.673162]).

No families dropped out of the study, and 16 of the 20 families completed 3 months of follow-up. Youths in both groups maintained any gains at the 3-month follow-up. In the PFIT group, mothers and fathers attended 95% of the family therapy sessions together, and among PFIT families with siblings of the youth with OCD, 6 brought a sibling to at least one session.

CBT alone is the front-line treatment for mild to moderate pediatric OCD, "but we’re not here to talk about those kids," Dr. Peris said. Previous studies have shown that 46%-79% of youths with OCD fail treatment with CBT, medication, or a combination of the two, depending on the treatment.

The study targeted treatment-resistant patients who also had dysfunctional families, which previous data identified as a predictor of poor response to CBT treatment for OCD.

Dr. Peris and her associates earlier identified three characteristics of dysfunctional families that interfere with a family’s ability to stop accommodating OCD symptoms: blame, family conflict, and poor family cohesion. These factors have an additive effect: only 14% of youths in families with all three factors responded to CBT, compared with 93% in families with none of these characteristics, Dr. Peris reported (J. Consult. Clin. Psychol. 2012;80:255-63).

"These features argue for some degree of family intervention in pediatric OCD treatment," she said.

PFIT aims to reduce hostility and blame, increase family cohesion, and reduce OCD accommodation to enhance the efficacy of exposure-based CBT. "None of this is meant to blame parents or families. They’re doing their best. We try to give them better ways to cope," she said.

Previous family interventions tended to rely on psychoeducation, with limited success in changing family dynamics, she noted. PFIT provides psychoeducation but also focuses on increasing parental self-efficacy (the sense that one is able to produce and regulate events in one’s life), providing parents with skills training in emotion regulation (including calm disengagement from challenging OCD episodes), and improving parenting skills such as scaffolding (recognizing the level of skill the child has mastered, and thinking of one level beyond that).

PFIT also addresses broader family dynamics, including reducing criticism, promoting positive problem-solving as a family, increasing cohesion, and creating a common language for communicating about OCD symptoms.

In the study, mothers in the PFIT group reported significantly lower levels of blame at week 24, compared with mothers in the control group. The PFIT families showed significant decreases in accommodation, blame, and family conflict, Dr. Peris reported.

"PFIT may be a better strategy than standard CBT for complex cases of OCD," she said.

Dr. Peris reported having no financial disclosures.

SAN FRANCISCO – An innovative family-focused treatment program for complex cases of pediatric obsessive-compulsive disorder that looked promising in a randomized, controlled pilot trial of 20 families has now accumulated experience with 35 families.

"We’re getting increasingly confident that we may have something here," Tara S. Peris, Ph.D., said at the annual meeting of the American Academy of Child and Adolescent Psychiatry.

A larger study is being planned of the adjunctive positive family interaction therapy (PFIT), which families in the prospective pilot study seemed to embrace. The study recruited families based on a primary diagnosis of pediatric obsessive-compulsive disorder (OCD) and an assessment of poor family functioning, and then randomized them to receive six sessions of standard therapy with individual child cognitive-behavioral therapy (CBT) or to standard therapy plus PFIT.

Seven of 10 patients in the PFIT group and 4 of 10 in the control group responded after six treatment sessions, as assessed on the Clinical Global Impressions of Improvement (CGI-I) scale by blinded raters. The 40% response rate in the control group "parallels what’s in other studies," noted Dr. Peris of the Semel Institute for Neuroscience and Human Behavior at the University of California, Los Angeles.

On the Children’s Yale–Brown Obsessive Compulsive Scale (CY-BOCS) of symptom severity, 5 of 10 patients in the PFIT group achieved remission, compared with 2 of 10 in the control group, reported Dr. Peris and her colleague at the institute, John Piacentini, Ph.D. (J. Clin. Child. Adolesc. Psychol. 2012 [doi: 10.1080/15374416.2012.673162]).

No families dropped out of the study, and 16 of the 20 families completed 3 months of follow-up. Youths in both groups maintained any gains at the 3-month follow-up. In the PFIT group, mothers and fathers attended 95% of the family therapy sessions together, and among PFIT families with siblings of the youth with OCD, 6 brought a sibling to at least one session.

CBT alone is the front-line treatment for mild to moderate pediatric OCD, "but we’re not here to talk about those kids," Dr. Peris said. Previous studies have shown that 46%-79% of youths with OCD fail treatment with CBT, medication, or a combination of the two, depending on the treatment.

The study targeted treatment-resistant patients who also had dysfunctional families, which previous data identified as a predictor of poor response to CBT treatment for OCD.

Dr. Peris and her associates earlier identified three characteristics of dysfunctional families that interfere with a family’s ability to stop accommodating OCD symptoms: blame, family conflict, and poor family cohesion. These factors have an additive effect: only 14% of youths in families with all three factors responded to CBT, compared with 93% in families with none of these characteristics, Dr. Peris reported (J. Consult. Clin. Psychol. 2012;80:255-63).

"These features argue for some degree of family intervention in pediatric OCD treatment," she said.

PFIT aims to reduce hostility and blame, increase family cohesion, and reduce OCD accommodation to enhance the efficacy of exposure-based CBT. "None of this is meant to blame parents or families. They’re doing their best. We try to give them better ways to cope," she said.

Previous family interventions tended to rely on psychoeducation, with limited success in changing family dynamics, she noted. PFIT provides psychoeducation but also focuses on increasing parental self-efficacy (the sense that one is able to produce and regulate events in one’s life), providing parents with skills training in emotion regulation (including calm disengagement from challenging OCD episodes), and improving parenting skills such as scaffolding (recognizing the level of skill the child has mastered, and thinking of one level beyond that).

PFIT also addresses broader family dynamics, including reducing criticism, promoting positive problem-solving as a family, increasing cohesion, and creating a common language for communicating about OCD symptoms.

In the study, mothers in the PFIT group reported significantly lower levels of blame at week 24, compared with mothers in the control group. The PFIT families showed significant decreases in accommodation, blame, and family conflict, Dr. Peris reported.

"PFIT may be a better strategy than standard CBT for complex cases of OCD," she said.

Dr. Peris reported having no financial disclosures.

SAN FRANCISCO – When youths get referred for help with symptoms that don’t quite meet diagnostic criteria for bipolar illness, there’s a 50-50 chance they’ll progress to a diagnosis of bipolar disorder I or II within 7 years. The odds are a coin toss.

The risk logically might be even lower in general clinical settings than in this defined group. That’s why Dr. David A. Axelson and his associates advocate using conservative criteria for diagnosing "bipolar not otherwise specified" (BP-NOS) in general clinics.

Sherry Boschert/IMNG Medical Media

Dr. Axelson won the American Academy of Child and Adolescent Psychiatry’s Klingenstein Third Generation Foundation Award for his longitudinal research on 140 children and adolescents who met an operationalized diagnosis of BP-NOS. At a median follow-up of 5 years, 45% had converted to bipolar disorder I or II (BP I/II) within a mean of 58 weeks after intake (J. Am. Acad. Child. Adolesc. Psychiatry 2011;50:1001-16.e3).

New data from the ongoing study show that 50% progressed to BP I/II at a median follow-up of 7 years, he said at the academy’s annual meeting. Symptoms for most of the youths in the COBY (Course and Outcome of Bipolar Youth) study far exceeded the minimum BP-NOS criteria at baseline.

Very few factors predicted whether patients would convert to BP I/II or not, and even those were not strong predictors, said Dr. Axelson, medical director of Child and Adolescent Bipolar Services Outpatient Program at the University of Pittsburgh’s Western Psychiatric Institute and Clinic.

Many children and adolescents present to clinics with manic symptomatology that does not meet diagnostic criteria for BP I/II in the DSM-IV. Clinicians walk a tightrope between intervening as early as possible for best treatment results and mislabeling (and then mistreating) some youths who don’t have bipolar illness.

The criteria for BP-NOS in the DSM-IV are vague and nonspecific, Dr. Axelson said. Based on his and other studies of "subthreshold" bipolar symptoms in children and adolescents, Dr. Axelson proposed that criteria for diagnosing BP-NOS in general clinical settings include:

• Use of full DSM symptom criteria for a hypomanic or manic episode.

Almost all of the children and adolescents in his COBY study met medical criteria for symptoms, he noted.

• Having hypomanic symptoms for most of the day.

"Similar to what we think about for major depression," Dr. Axelson said. "This most-of-the-day specifier will be in DSM 5 for manic or hypomanic episodes."

• At least one episode of 2-day duration.

• At least four recurrent episodes.

Almost all the children and adolescents with BP-NOS in the COBY study already had recurrent episodes.

These criteria are "probably the best balance between sensitivity and specificity, understanding the fact that this is going to miss some kids in the early phase of illness," he said.

The COBY study enrolled 153 youths seen at three academic medical centers, 140 of whom had at least one follow-up visit. The main reasons the diagnosis was BP-NOS instead of BP I/II were because the duration of manic or hypomanic episodes was too short (only 1-3 days in 86% of patients); the youth had hypomania with no major depressive episode (11%); or the youth did not have the required number of symptoms for BP I/II (3%).

The investigators tracked at least 17 factors that they hypothesized might help predict which youths would progress to BP I/II. "Much to my surprise, very little of this actually predicted future onset," Dr. Axelson said. The main predictor was a family history of mania or hypomania and, "the effect size isn’t huge."

At intake, the 63 patients who later converted to BP I/II were significantly more likely to have a family history of mania or hypomania (64%) or depression (90%), compared with the 77 patients who did not convert to BP I/II (40% and 78%), respectively.

A total of 58% of youths with a family history of mania or hypomania converted to BP I/II by a median 5-year follow-up, compared with 36% of youths without this family history. The newest data suggest that by 8 years, two-thirds of youths with a family history of mania or hypomania convert to BP I/II, compared with just under half of youths without this family history, he reported.

"One thing that’s interesting is the progression rate keeps going up in both groups if you follow them longer," Dr. Axelson said. "These kids continue to go forward in converting to bipolar illness."

A multivariate analysis found that a family history of mania or hypomania tripled the risk for progression to BP I/II. So did white race, which "we can’t really explain," he said. Any lifetime history of psychiatric hospitalization multiplied the risk for progression 2.5 times. Higher scores on the Young Mania Rating Scale in the past month increased the risk of progression by 3%, which was statistically significant.

Any lifetime history of psychotic symptoms, however, was significantly and negatively associated with progression to BP I/II, "something we still don’t fully understand," Dr. Axelson said. Patients with a history of psychotic symptoms were 71% less likely to convert to BP I/II.

Having a family history of mania or hypomania is "a useful predictor, because more kids with family history did convert, however it’s not so strong that you can say it’s definitive," he said. "Lots of kids who had a family history didn’t progress, and a full third of the kids who didn’t have a family history progressed."

Dr. Axelson reported having no financial disclosures.

SAN FRANCISCO – When youths get referred for help with symptoms that don’t quite meet diagnostic criteria for bipolar illness, there’s a 50-50 chance they’ll progress to a diagnosis of bipolar disorder I or II within 7 years. The odds are a coin toss.

The risk logically might be even lower in general clinical settings than in this defined group. That’s why Dr. David A. Axelson and his associates advocate using conservative criteria for diagnosing "bipolar not otherwise specified" (BP-NOS) in general clinics.

Sherry Boschert/IMNG Medical Media

Dr. Axelson won the American Academy of Child and Adolescent Psychiatry’s Klingenstein Third Generation Foundation Award for his longitudinal research on 140 children and adolescents who met an operationalized diagnosis of BP-NOS. At a median follow-up of 5 years, 45% had converted to bipolar disorder I or II (BP I/II) within a mean of 58 weeks after intake (J. Am. Acad. Child. Adolesc. Psychiatry 2011;50:1001-16.e3).

New data from the ongoing study show that 50% progressed to BP I/II at a median follow-up of 7 years, he said at the academy’s annual meeting. Symptoms for most of the youths in the COBY (Course and Outcome of Bipolar Youth) study far exceeded the minimum BP-NOS criteria at baseline.

Very few factors predicted whether patients would convert to BP I/II or not, and even those were not strong predictors, said Dr. Axelson, medical director of Child and Adolescent Bipolar Services Outpatient Program at the University of Pittsburgh’s Western Psychiatric Institute and Clinic.

Many children and adolescents present to clinics with manic symptomatology that does not meet diagnostic criteria for BP I/II in the DSM-IV. Clinicians walk a tightrope between intervening as early as possible for best treatment results and mislabeling (and then mistreating) some youths who don’t have bipolar illness.

The criteria for BP-NOS in the DSM-IV are vague and nonspecific, Dr. Axelson said. Based on his and other studies of "subthreshold" bipolar symptoms in children and adolescents, Dr. Axelson proposed that criteria for diagnosing BP-NOS in general clinical settings include:

• Use of full DSM symptom criteria for a hypomanic or manic episode.

Almost all of the children and adolescents in his COBY study met medical criteria for symptoms, he noted.

• Having hypomanic symptoms for most of the day.

"Similar to what we think about for major depression," Dr. Axelson said. "This most-of-the-day specifier will be in DSM 5 for manic or hypomanic episodes."

• At least one episode of 2-day duration.

• At least four recurrent episodes.

Almost all the children and adolescents with BP-NOS in the COBY study already had recurrent episodes.

These criteria are "probably the best balance between sensitivity and specificity, understanding the fact that this is going to miss some kids in the early phase of illness," he said.

The COBY study enrolled 153 youths seen at three academic medical centers, 140 of whom had at least one follow-up visit. The main reasons the diagnosis was BP-NOS instead of BP I/II were because the duration of manic or hypomanic episodes was too short (only 1-3 days in 86% of patients); the youth had hypomania with no major depressive episode (11%); or the youth did not have the required number of symptoms for BP I/II (3%).

The investigators tracked at least 17 factors that they hypothesized might help predict which youths would progress to BP I/II. "Much to my surprise, very little of this actually predicted future onset," Dr. Axelson said. The main predictor was a family history of mania or hypomania and, "the effect size isn’t huge."

At intake, the 63 patients who later converted to BP I/II were significantly more likely to have a family history of mania or hypomania (64%) or depression (90%), compared with the 77 patients who did not convert to BP I/II (40% and 78%), respectively.

A total of 58% of youths with a family history of mania or hypomania converted to BP I/II by a median 5-year follow-up, compared with 36% of youths without this family history. The newest data suggest that by 8 years, two-thirds of youths with a family history of mania or hypomania convert to BP I/II, compared with just under half of youths without this family history, he reported.

"One thing that’s interesting is the progression rate keeps going up in both groups if you follow them longer," Dr. Axelson said. "These kids continue to go forward in converting to bipolar illness."

A multivariate analysis found that a family history of mania or hypomania tripled the risk for progression to BP I/II. So did white race, which "we can’t really explain," he said. Any lifetime history of psychiatric hospitalization multiplied the risk for progression 2.5 times. Higher scores on the Young Mania Rating Scale in the past month increased the risk of progression by 3%, which was statistically significant.

Any lifetime history of psychotic symptoms, however, was significantly and negatively associated with progression to BP I/II, "something we still don’t fully understand," Dr. Axelson said. Patients with a history of psychotic symptoms were 71% less likely to convert to BP I/II.

Having a family history of mania or hypomania is "a useful predictor, because more kids with family history did convert, however it’s not so strong that you can say it’s definitive," he said. "Lots of kids who had a family history didn’t progress, and a full third of the kids who didn’t have a family history progressed."

Dr. Axelson reported having no financial disclosures.

SAN FRANCISCO – When youths get referred for help with symptoms that don’t quite meet diagnostic criteria for bipolar illness, there’s a 50-50 chance they’ll progress to a diagnosis of bipolar disorder I or II within 7 years. The odds are a coin toss.

The risk logically might be even lower in general clinical settings than in this defined group. That’s why Dr. David A. Axelson and his associates advocate using conservative criteria for diagnosing "bipolar not otherwise specified" (BP-NOS) in general clinics.

Sherry Boschert/IMNG Medical Media

Dr. Axelson won the American Academy of Child and Adolescent Psychiatry’s Klingenstein Third Generation Foundation Award for his longitudinal research on 140 children and adolescents who met an operationalized diagnosis of BP-NOS. At a median follow-up of 5 years, 45% had converted to bipolar disorder I or II (BP I/II) within a mean of 58 weeks after intake (J. Am. Acad. Child. Adolesc. Psychiatry 2011;50:1001-16.e3).

New data from the ongoing study show that 50% progressed to BP I/II at a median follow-up of 7 years, he said at the academy’s annual meeting. Symptoms for most of the youths in the COBY (Course and Outcome of Bipolar Youth) study far exceeded the minimum BP-NOS criteria at baseline.

Very few factors predicted whether patients would convert to BP I/II or not, and even those were not strong predictors, said Dr. Axelson, medical director of Child and Adolescent Bipolar Services Outpatient Program at the University of Pittsburgh’s Western Psychiatric Institute and Clinic.

Many children and adolescents present to clinics with manic symptomatology that does not meet diagnostic criteria for BP I/II in the DSM-IV. Clinicians walk a tightrope between intervening as early as possible for best treatment results and mislabeling (and then mistreating) some youths who don’t have bipolar illness.

The criteria for BP-NOS in the DSM-IV are vague and nonspecific, Dr. Axelson said. Based on his and other studies of "subthreshold" bipolar symptoms in children and adolescents, Dr. Axelson proposed that criteria for diagnosing BP-NOS in general clinical settings include:

• Use of full DSM symptom criteria for a hypomanic or manic episode.

Almost all of the children and adolescents in his COBY study met medical criteria for symptoms, he noted.

• Having hypomanic symptoms for most of the day.

"Similar to what we think about for major depression," Dr. Axelson said. "This most-of-the-day specifier will be in DSM 5 for manic or hypomanic episodes."

• At least one episode of 2-day duration.

• At least four recurrent episodes.

Almost all the children and adolescents with BP-NOS in the COBY study already had recurrent episodes.

These criteria are "probably the best balance between sensitivity and specificity, understanding the fact that this is going to miss some kids in the early phase of illness," he said.

The COBY study enrolled 153 youths seen at three academic medical centers, 140 of whom had at least one follow-up visit. The main reasons the diagnosis was BP-NOS instead of BP I/II were because the duration of manic or hypomanic episodes was too short (only 1-3 days in 86% of patients); the youth had hypomania with no major depressive episode (11%); or the youth did not have the required number of symptoms for BP I/II (3%).

The investigators tracked at least 17 factors that they hypothesized might help predict which youths would progress to BP I/II. "Much to my surprise, very little of this actually predicted future onset," Dr. Axelson said. The main predictor was a family history of mania or hypomania and, "the effect size isn’t huge."

At intake, the 63 patients who later converted to BP I/II were significantly more likely to have a family history of mania or hypomania (64%) or depression (90%), compared with the 77 patients who did not convert to BP I/II (40% and 78%), respectively.

A total of 58% of youths with a family history of mania or hypomania converted to BP I/II by a median 5-year follow-up, compared with 36% of youths without this family history. The newest data suggest that by 8 years, two-thirds of youths with a family history of mania or hypomania convert to BP I/II, compared with just under half of youths without this family history, he reported.

"One thing that’s interesting is the progression rate keeps going up in both groups if you follow them longer," Dr. Axelson said. "These kids continue to go forward in converting to bipolar illness."

A multivariate analysis found that a family history of mania or hypomania tripled the risk for progression to BP I/II. So did white race, which "we can’t really explain," he said. Any lifetime history of psychiatric hospitalization multiplied the risk for progression 2.5 times. Higher scores on the Young Mania Rating Scale in the past month increased the risk of progression by 3%, which was statistically significant.

Any lifetime history of psychotic symptoms, however, was significantly and negatively associated with progression to BP I/II, "something we still don’t fully understand," Dr. Axelson said. Patients with a history of psychotic symptoms were 71% less likely to convert to BP I/II.

Having a family history of mania or hypomania is "a useful predictor, because more kids with family history did convert, however it’s not so strong that you can say it’s definitive," he said. "Lots of kids who had a family history didn’t progress, and a full third of the kids who didn’t have a family history progressed."

Dr. Axelson reported having no financial disclosures.