Pediatric bipolar disorder: emerging diagnostic and treatment approaches

Sleep quality predicts future mood symptoms in adolescents with bipolar disorder

BACKGROUND

Poor sleep is prevalent in adolescents with bipolar disorder, precedes illness onset, and is associated with worse mood symptoms. We examined interrelationships between sleep quality and mood symptoms in adolescents with bipolar disorder, particularly effects of sleep quality on emergent mood symptoms.

METHODS

Adolescents with bipolar disorder participated in a two-year longitudinal treatment study. Sleep quality (Pittsburgh Sleep Quality Index, PSQI) was assessed quarterly during treatment (baseline, 3-, 6-, 9-, 12-month visits) and twice during follow-up (18-, 24-month visits). Mood symptoms (ALIFE Psychiatric Status Ratings) were retrospectively rated weekly by an independent clinician. Lag models tested whether sleep quality predicted next month's mood symptoms and whether mood symptoms predicted future sleep quality.

RESULTS

Adolescents with bipolar disorder had poor sleep quality. Sleep quality initially improved but remained stable thereafter. Worse sleep quality at 6-months predicted worse depression, hypomania, and suicidal ideation the following month. Sleep quality was worse for adolescents who had a suicide attempt during the study compared to those who did not and was worse preceding months with a suicide attempt compared to months without attempts. Alternatively, worse depression predicted worse future sleep quality at baseline, 3-, and 18-months and worse suicidal ideation predicted worse future sleep quality at baseline, 12-, and 18-months.

LIMITATIONS

Mood symptoms were rated retrospectively and the PSQI may not capture all dimensions of sleep important for mood symptoms.

CONCLUSIONS

Targeted evidence-based sleep treatment in adolescents with bipolar disorder may alleviate sleep problems and have additional benefits on mood symptoms and suicidality risk.

Emotion regulation in pediatric bipolar disorder: A meta-analysis of published studies

BACKGROUND

Emotion regulation is a relatively recent topic in psychiatry, and has only recently begun to be tested across Pediatric Bipolar Disorder (PBD). To date, no meta-analysis has investigated the presence of emotion regulation deficits in PBD patients.

OBJECTIVES

The aim of this study is to understand where the literature stands on this topic, as well as how different researchers are measuring and grasping the concept of emotion regulation in pediatric bipolar disorders.

METHODS

A systematic search of trials using the terms ("Pediatric Bipolar Disorder") AND ("Emotion Regulation" OR "Affect Regulation" OR "Mood Lability" OR "Mood Instability" OR "Irritability") was conducted using PubMed, Google Scholar, ResearchGate, Web of Science and Psych Info databases. Of the initial 366 articles identified, 8 met eligibility criteria for the meta-analysis and were included in this study.

RESULTS

There is a statistically significant difference in Accuracy in Emotion Regulation tasks, with a tendency for lower accuracy in PBD patients; however, both groups did not differ statistically regarding Response Time.

CONCLUSION

Our data suggests that PBD patients do present emotion regulation deficits, particularly regarding facial emotion recognition and affective language interference tasks mediated by cognitive assignments. These results have important implications in developing novel psychotherapeutic interventions for this population.

Bipolar disorder in children

Although bipolar disorder historically was thought to only occur rarely in children and adolescents, there has been a significant increase in children and adolescents who are receiving this diagnosis more recently (Carlson, 2005). Nonetheless, the applicability of the current bipolar disorder diagnostic criteria for children, particularly preschool children, remains unclear, even though much work has been focused on this area. As a result, more work needs to be done to further the understanding of bipolar symptoms in children. It is hoped that this paper can assist psychologists and other health service providers in gleaning a snapshot of the literature in this area so that they can gain an understanding of the diagnostic criteria and other behaviors that may be relevant and be informed about potential approaches for assessment and treatment with children who meet bipolar disorder criteria. First, the history of bipolar symptoms and current diagnostic criteria will be discussed. Next, assessment strategies that may prove helpful for identifying bipolar disorder will be discussed. Then, treatments that may have relevance to children and their families will be discussed. Finally, conclusions regarding work with children who may have a bipolar disorder diagnosis will be offered.

Psychiatric considerations in children and adolescents with HIV/AIDS

The psychosocial impact of human immunodeficiency virus (HIV) disease has been recognized since the beginning of the epidemic for affected adults, but there has been less focus on the impact of HIV on young people. Among HIV-positive (HIV+) adults, high levels of distress, psychiatric symptoms, and their associations with worse health outcomes were recognized early in the epidemic. Subsequently, many studies have focused on understanding the prevalence of psychiatric symptoms among HIV+ adults and on identifying effective treatments for these symptoms. Fewer studies have examined these symptoms and their treatments among HIV+ children and adolescents. This article reviews what is known about psychiatric syndromes among HIV+ youths, their treatments, and other psychosocial factors of concern to the psychiatrist when treating children and adolescents with HIV disease.

Psychopharmacology of pediatric bipolar disorders in children and adolescents

Pediatric bipolar disorder (PBD) is a chronic and disabling illness often leading to serious disruption in the lives of children and adolescents with this condition. Until recently, methodologically stringent data to guide pharmacologic interventions in the youth were scarce. However, clinical trials conducted recently have expanded the existing evidence base, and new data are emerging rapidly. Recent studies have examined the use of lithium, anticonvulsants, and atypical antipsychotics for acute and long-term treatment of PBD. Despite these new advances, further placebo-controlled trials investigating the efficacy and safety of pharmacologic treatment strategies for young people with bipolar disorder are still needed.

Psychiatric considerations in children and adolescents with HIV/AIDS

The psychosocial impact of human immunodeficiency virus (HIV) disease has been recognized since the beginning of the epidemic for affected adults, but there has been less focus on the impact of HIV on young people. Among HIV-positive (HIV+) adults, high levels of distress, psychiatric symptoms, and their associations with worse health outcomes were recognized early in the epidemic. Subsequently, many studies have focused on understanding the prevalence of psychiatric symptoms among HIV+ adults and on identifying effective treatments for these symptoms. Fewer studies have examined these symptoms and their treatments among HIV+ children and adolescents. This article reviews what is known about psychiatric syndromes among HIV+ youths, their treatments, and other psychosocial factors of concern to the psychiatrist when treating children and adolescents with HIV disease.

Pediatric bipolar disorder: evidence for prodromal states and early markers

BACKGROUND

Childhood bipolar disorder remains a controversial but increasingly diagnosed disorder that is associated with significant impairment, chronic course and treatment resistance. Therefore, the search for prodromes or early markers of risk for later childhood bipolar disorder may be of great importance for prevention and/or early identification.

METHODS

Literature searches were conducted to identify reviews, case reports and empirical papers addressing the issue of prodromes of childhood bipolar disorder.

RESULTS

A total of 54 articles were found that related to bipolar prodromes, risk factors for later childhood bipolar disorder, childhood risk for adult bipolar disorder, mania manifestations in early childhood, and neuropsychological and biological markers of childhood bipolar disorder. A review of articles suggest (a) childhood bipolar prodromes may be detectable prior to the onset of the disorder, (b) prodromal symptoms may display episodicity during childhood, (c) there is evidence of possible endophenotypic markers such as deficits in executive function, sustained attention, and emotion labeling, (d) there is a potential association with functional, structural, and biochemical alterations evident in brain structures involved in mood regulation, (e) a link between childhood bipolar disorder with early tempermental markers, such as emotional regulation and behavioral disinhibition and (f) there is some early but promising evidence of effective psychotherapeutic preventions.

CONCLUSIONS

There has been very limited investigation of early prodromes of childhood bipolar disorder. Based on the promising findings of prodromes as well as high-risk states and possible endophenotypic markers, more controlled and targeted investigations into the early markers of bipolar disorder appear warranted and potentially fruitful. Until such longitudinal studies with appropriate controls are conducted, specific markers for bipolar prodromes will remain elusive, although evidence suggests they are manifest in at least some subgroups. The finding of promising psychotherapeutic prevention programs underscores the need to find specific and sensitive markers of bipolar prodromes in childhood.

Treatment of psychiatric disorders in children and adolescents with HIV/AIDS

We could not have predicted that HIV/AIDS would become one of our greatest public health challenges worldwide when the first cases were identified in the 1980s. More than 22 million people have died from the disease, and HIV is now the seventh-leading cause of death in the United States among 15- to 24-year-olds. At the beginning of this pandemic, most HIV infections of youth were acquired congenitally. Prenatal screening of pregnant women, early detection, and antiretroviral therapies have reduced mother-to-child transmission. Children born with HIV infections are now young adults living with HIV, while other adolescents are acquiring HIV primarily through high-risk behaviors. Associations between psychiatric symptoms and poor health outcomes have been recognized among adults. Few studies have examined these factors among youth. We review what is known about psychiatric syndromes among HIV-positive youth, and their treatments.

Prescribing patterns for treatment of pediatric bipolar disorder in a specialty clinic

OBJECTIVE

The aim of this study was to describe prescribing practices in the treatment of pediatric bipolar disorder in a university practice setting.

METHOD

A retrospective chart review was performed on 53 youths diagnosed using Diagnostic and Statistical Manual of Mental Disorders, 4(th) edition (DSM-IV), criteria with bipolar spectrum disorder under the active care of child psychiatrists practicing in a pediatric psychopharmacology specialty clinic. Current medications, doses, and related adverse events were recorded. Clinicians were asked to provide a target disorder (bipolar mania/mixed state, depression, attention deficit hyperactivity disorder [ADHD], or anxiety) for each medication to the best of their ability. The Clinical Global Impressions-Severity (CGI-S) scale was used to measure severity of each disorder before treatment and the Clinical Global Impressions-Improvement (CGI-I) was used to quantify the magnitude of improvement with treatment. Meaningful improvement of the disorder was defined by CGI-I score of 1 or 2.

RESULTS

The mean number of psychotropic medications per patient was 3.0 +/- 1.6. A total of 68% of patients were treated for co-morbid disorders; 23% of patients were treated with monotherapy, primarily with second-generation antipsychotics. Mania improved in 80% of cases, mixed state improved in 57% of cases, ADHD improved in 56% of cases, anxiety improved in 61% of cases, and depression improved in 90% of cases.

CONCLUSION

The management of pediatric bipolar disorder often requires multiple medications. For the treatment of mania/mixed states, clinicians prescribed second-generation antipsychotics more frequently than mood stabilizers, especially in the context of monotherapy. Co-morbidity was a frequent problem with moderate success obtained with combined pharmacotherapy approaches. Further psychosocial strategies to augment pharmacotherapy may improve outcome while reducing the medication burden in pediatric bipolar disorder.

Attention-deficit-hyperactivity disorder: an update

Attention-deficit-hyperactivity disorder (ADHD) is a common neuropsychiatric disorder that impairs social, academic, and occupational functioning in children, adolescents, and adults. In patients with ADHD, neurobiologic research has shown a lack of connectivity in key brain regions, inhibitory control deficits, delayed brain maturation, and noradrenergic and dopaminergic dysfunction in multiple brain regions. The prevalence of this disorder in the United States is 6-9% in youth (i.e., children and adolescents) and 3-5% in adults. Prevalence rates for youth are similar worldwide. Children with ADHD are at greater risk than children without ADHD for substance abuse and delinquency whether or not they receive drug therapy; however, early treatment with psychoeducation as well as drug therapy and/or behavioral intervention may decrease negative outcomes of ADHD, including the rate of conduct disorder and adult antisocial personality disorder. Drug therapy is effective for all age groups, even preschoolers, and for late-onset ADHD in adults. Stimulants, such as methylphenidate and amphetamine, are the most effective therapy and have a good safety profile; although recent concerns of sudden unexplained death, psychiatric adverse effects, and growth effects have prompted the introduction of other therapies. Atomoxetine, a nonstimulant, has no abuse potential, causes less insomnia than stimulants, and poses minimal risk of growth effects. Other drug options include clonidine and guanfacine, but both can cause bradycardia and sedation. Polyunsaturated fatty acids (fish oil), acetyl-L-carnitine, and iron supplements (for youth with low ferritin levels) show promise in improving ADHD symptoms. As long-term studies show that at least 50% of youth are nonadherent with their drug therapy as prescribed over a 1-year period, long-acting formulations (administered once/day) may improve adherence. Comorbid conditions are common in patients with ADHD, but this patient population can be treated effectively with individualized treatment regimens of stimulants, atomoxetine, or bupropion, along with close monitoring.

A developmental approach to the treatment of bipolar disorder: IPSRT with an adolescent

AIM

This case study explains how a psychotherapy previously used with adults can be used with adolescents by focusing on the specific developmental issues associated with adolescence.

BACKGROUND

Bipolar disorder is a damaging disorder to experience during the developmental phase of adolescence. Interpersonal social rhythm psychotherapy has been developed as an adjunct to medication for managing bipolar disorder and shows some promising outcomes in adults.

DESIGN

This is a single case study design drawn from a larger randomised control trial of two psychotherapies for bipolar disorder. The case study addressed the question: How can Interpersonal social rhythm therapy be applied with adolescents who have bipolar disorder?

METHOD

This study used a purposeful sampling process by selecting the youngest adolescent participating in the randomised control trial. All the subject's sessions of Interpersonal social rhythm therapy were taped, transcribed and analysed. The analysis involved describing the process of psychotherapy as it occurred over time, mapping the process as a trajectory across the three phases of psychotherapy experience and focusing the analysis around the impact of bipolar disorder and IPSRT on adolescent developmental issues, specifically the issue of identity development.

RESULTS

Interpersonal social rhythm therapy allowed the therapist to address developmental issues within its framework. As a result of participation in the psychotherapy the adolescent was able to manage her mood symptoms and develop a sense of identity that was age-appropriate.

CONCLUSION

Interpersonal social rhythm therapy provided the adolescent in the case study the opportunity to consider what it meant to have bipolar disorder and to integrate this meaning into her sense of self.

RELEVANCE TO CLINICAL PRACTICE

Bipolar disorder is a chronic and recurring disorder that can have a serious impact on development and functioning. Interpersonal social rhythm therapy provides an approach to nursing care that enables adolescents to improve social functioning.

Ziprasidone in the treatment of mania in bipolar disorder

Ziprasidone is an atypical antipsychotic with a unique receptor-binding profile. Currently, ziprasidone is approved by the US Food and Drug Administration for the acute treatment of psychosis in schizophrenia and mania in bipolar disorder. When compared to certain other atypical antipsychotics, ziprasidone appears to have a relatively benign side effect profile, especially as regards metabolic effects eg, weight gain, serum lipid elevations and glucose dysregulation. Taken together, these data suggest that ziprasidone may be a first line treatment for patients with bipolar mania. However, ziprasidone is a relatively new medication for which adverse events after long-term use and/or in vulnerable patient populations must be studied. Unstudied areas of particular importance include the efficacy and safety of ziprasidone in the treatment of bipolar depression and relapse prevention of mania as, well as in the subpopulations of pregnant women, the elderly and pediatric patients. The emergence of mania in patients taking ziprasidone is another topic for further study.

Management of children with autism spectrum disorders

Pediatricians have an important role not only in early recognition and evaluation of autism spectrum disorders but also in chronic management of these disorders. The primary goals of treatment are to maximize the child's ultimate functional independence and quality of life by minimizing the core autism spectrum disorder features, facilitating development and learning, promoting socialization, reducing maladaptive behaviors, and educating and supporting families. To assist pediatricians in educating families and guiding them toward empirically supported interventions for their children, this report reviews the educational strategies and associated therapies that are the primary treatments for children with autism spectrum disorders. Optimization of health care is likely to have a positive effect on habilitative progress, functional outcome, and quality of life; therefore, important issues, such as management of associated medical problems, pharmacologic and nonpharmacologic intervention for challenging behaviors or coexisting mental health conditions, and use of complementary and alternative medical treatments, are also addressed.

Pharmacotherapeutic strategies for pediatric bipolar disorder

There has been a recent increase in recognition and diagnosis of pediatric bipolar disorder (PBD), along with an increase in prescriptions for psychotropic medications for treating children suffering from this chronic, potentially disabling disorder. Lithium remains the only FDA-approved mood stabilizer for use in children > 12 years of age and along with valproic acid and carbamazepine, forms the triad of traditional mood stabilizers used for initiation of treatment for PBD. There has been a recent surge in the use of atypical antipsychotics in PBD, which may be due to their relative ease of administration and lack of requirement for serum level monitoring. A combination of traditional mood stabilizers along with atypical antipsychotics is commonly used in clinical practice, despite a lack of compelling empirical data. Although there is an urgent need for controlled studies on the available treatment options and strategies in PBD, recent expert consensus guidelines and emerging controlled pharmacotherapy data on PBD will lay the platform for future scientific research in the area.

The status of pharmacotherapy for autism spectrum disorders

The use of pharmacologic agents as a component of treatment for children and adults with autism spectrum disorders is common and a substantial body of literature describing controlled and open-label clinical trials now exists to guide clinical practice. Empiric evidence of efficacy of risperidone, methylphenidate and some selective serotonin re-uptake inhibitors for maladaptive behaviors commonly associated with autism spectrum disorders has increased substantially in recent years. Preliminary controlled trials of valproate, atomoxetine, alpha-2 adrenergic agonists and olanzapine are promising. In addition to traditional psychotropic medications, investigators have examined the potential role of a variety of agents with glutamatergic or cholinergic mechanisms, and the results warrant further investigation. Although psychotropic medications are effective in treating some important associated behaviors, evidence of significant impact on the core features of autism spectrum disorders is very limited.

Adherence to pharmacological treatment for juvenile bipolar disorder

OBJECTIVE

The objective of this study was to describe the prevalence and correlates of adherence to divalproex sodium (DVPX) and lithium carbonate (Li) combination treatment during the initial stabilization treatment phase.

METHOD

Adherence to Li/DVPX combination therapy was measured by the presence or absence of minimum serum concentrations of DVPX (50 microg/mL) or Li (0.6 mmol/L). Secondary measures included pill count, patient/parent report, and clinical judgment. Correlates of adherence, including patient characteristics, medication side effects, and family variables, were evaluated.

RESULTS

One hundred seven patients (70 males and 37 females) were studied. The proportion of serum concentrations in the therapeutic range across the study period was 0.84 for DVPX and 0.66 for Li. Maternal (r = -0.31; p<.01) and paternal (r = -0.44; p < .01) hospitalization for a psychiatric disorder and less adaptive family functioning (r=-0.26; p < .05) related to treatment nonadherence for DVPX. Better treatment adherence to DVPX (r = 0.21; p < .05) and Li (r = 0.23; p < .05) was associated with a greater number of side effects, whereas male sex was associated with worse adherence to both DVPX (r= -0.24; p < .05) and Li (r = -0.22; p < .05) pharmacotherapy. Clinical response to treatment correlated with adherence to DVPX treatment (r = 0.33; p < .01).

CONCLUSIONS

Nonadherence may limit the statistical power of treatment efficacy studies and the effectiveness of pharmacotherapy treatment for juvenile BPD and necessitate strategies to evaluate and enhance levels of treatment adherence.

Early identification and high-risk strategies for bipolar disorder

OBJECTIVES

To describe and compare the relative merits of different identification strategies for individuals at risk for bipolar disorder (BPD).

METHODS

Selective review of data that support early identification in BPD, with a particular focus on emerging clinical high-risk strategies.

RESULTS

Early detection of individuals at risk for BPD can utilize genetic, endophenotypic and clinical methods. Most published work focuses on genetic familial endophenotypic risk markers for BPD. However, despite encouraging results, problems with specificity and sensitivity limit the application of these data to early prevention programs. In addition, offspring studies of BPD patients systematically exclude the majority of subjects without a first-degree bipolar relative. On the other hand, emerging work in the clinical-high-risk arena has already produced encouraging results. Although still preliminary, the identification of individuals in subsyndromal or attenuated symptom 'prodromal' stages of BPD seems to be an under-researched area that holds considerable promise deserving increased attention. Required next steps include the development of rating tools for attenuated and subsyndromal manic and depressive symptoms and of prodromal criteria that will allow prodromal symptomatology to be systematically studied in patients with recent-onset bipolar, as well as in prospective population-based phenomenology trials and attenuated symptom-based high-risk studies.

CONCLUSIONS

Given the current limitations of each early identification method, combining clinical, endophenotypic and genetic strategies will increase prediction accuracy. Since reliable biological markers for BPD have not been established and since most patients with BPD lack a first-degree relative with this disorder, clinical high-risk approaches have great potential to inform early identification and intervention programs.

Pediatric Bipolar Disorder: Evidence-Based Psychopharmacological Treatments

TOPIC

Pediatric bipolar disorder can cause severe disturbances in global functioning. Diagnosing pediatric bipolar disorder is challenging due to the range of symptom expression, developmental differences as compared to adults, presence of comorbid disorders, and developing diagnostic criteria. Treating this disorder can be equally challenging due to frequent symptom relapse and the dearth of research until recently on effective psychopharmacological interventions that guide clinical prescribing practices.

PURPOSE

This paper will help child psychiatric nurses have a better understanding of the unique presentation of pediatric bipolar disorder to facilitate selection of appropriate medication treatment options, taking into account symptom presentation, presence of comorbid diagnosis, drug efficacy, adverse effects, and drug-drug interactions based on research findings.

SOURCES

Literature specific to assessment and psychopharmacological treatment of pediatric bipolar disorder was reviewed.

CONCLUSIONS

Screening of youth with mood spectrum problems for bipolar disorder should occur in every diagnostic assessment and should be ongoing due to range of mood symptoms and the cyclical and episodic nature of this disorder. Youth with bipolar disorder may manifest symptoms and course that differ from adults. Additionally, co-occuring disorders are common in this population, which can complicate medication selection. Psychopharmacological treatment with the use of specific mood stabilizers and/or atypical antipsychotic medications is warranted depending on symptom presentation; however, monotherapy with mood stabilizers has not demonstrated effectiveness in long-term remission of pediatric bipolar symptoms. Recent research indicates that a combined treatment with two mood stabilizers or a mood stabilizer and an antipsychotic holds promising results for pediatric bipolar I, for youth with acute manic symptoms plus psychosis, and for long-term remission of symptoms.

Diagnóstico e tratamento de transtorno bipolar e TDAH na infância: desafios na prática clínica

O transtorno de humor bipolar (THB) e o transtorno do déficit de atenção e hiperatividade (TDAH) são enfermidades graves, de evolução crônica e que geram forte impacto social, familiar e educacional. Por compartilharem sintomas comuns e freqüentemente se apresentarem em comorbidade, o seu diagnóstico diferencial torna-se difícil, porém imprescindível, visto que medicamentos utilizados no tratamento do TDAH podem agravar a bipolaridade em crianças não tratadas. São encontradas taxas que variam de 49% a 87% de diagnóstico de TDAH em crianças e adolescentes com THB. Crianças com ambos os transtornos têm um curso geralmente mais grave. São indivíduos com taxas maiores de sintomas psicóticos, depressão, problemas escolares, hospitalização, ansiedade e comportamentos disruptivos. A criança com transtorno de humor bipolar TDAH deve iniciar o tratamento com estabilizadores de humor, visto que o impacto dos sintomas maníacos é maior do que o dos sintomas de TDAH. Se os sintomas de desatenção, impulsividade e hiperatividade persistem após a estabilização do humor, pode-se preconizar o tratamento para o TDAH com o uso de psicoestimulantes.

Pharmacological interventions for bipolar youth: Developmental considerations

Despite the high prevalence rate, there have been relatively few controlled studies to systematically examine pharmacological treatments for children and adolescents with bipolar disorder. We review the differences in clinical characteristics between youth and adults with bipolar disorder and the extant literature of pharmacological treatments for children and adolescents with bipolar disorder, as well as discuss the effectiveness of pharmacological interventions for treating children and adolescents who are at familial risk for developing bipolar disorder. Although the number of controlled studies of youth with manic and mixed episodes is rapidly growing, there are few studies examining treatments for depression and the prevention of recurrent affective episodes in this population. Although children and adolescents with bipolar disorder commonly present with co-occurring psychiatric disorders, such as attention-deficit/hyperactivity disorder, there are limited data to guide the treatment of these patients. Recently, studies have begun to characterize prodromal manifestations of bipolar disorder and identify early intervention strategies for treating children and adolescents with an elevated risk for developing bipolar disorder.

Review of antipsychotics in children and adolescents

The use of antipsychotics in children and adolescents in the clinical setting is increasing. This article reviews 77 clinical trials published in the last 10 years, investigating their efficacy, effectiveness, safety and pharmacokinetic data in paediatric populations. The diagnostic categories in which the antipsychotics are commonly used (schizophrenia, pervasive developmental disorders, Tourette's disorder, mental retardation/subaverage intelligence, mood disorders and disruptive behaviour disorders) were used in order to review the evidence and effectiveness. All randomised, double-blind, placebo-controlled trials from the past decade are also summarised. This review refers to recent relevant practice parameters, guidelines and reviews throughout the text. Consistent with previous reviews, it is concluded that the recent trend of increased use of antipsychotics in children and adolescents is not adequately supported by evidence. Specific suggestions have been provided on how to incorporate the existing evidence base into clinical decision making. The review ends with the authors' opinion on the clinical and research implications for the field and future directions.