Unsuspected depressive mania in pre-pubertal Hispanic children referred for the treatment of 'depression' with history of social 'deviance'

Trans Youth Talk Back: A Foucauldian Discourse Analysis of Transgender Minors' Accounts of Healthcare Access

Contemporary transgender youth in the U.S. today face increasing stigmatization as extraordinary legislative attacks intensify discrimination and exclusion of these young people in healthcare, recreation, and school life. These attacks reflect broader political, religious, and cultural ideologies embedded in systems of power that regulate the provision of healthcare for American transgender youth. We apply Foucauldian discourse analysis and a theory-driven conceptual framework for structural analysis of transgender health inequities-Intersectionality Research for Transgender Health Justice-to identify discourses youth encounter within healthcare practice. We analyzed data from interviews conducted in Western Washington State with youth ages 13-17 (n =11) and asked how transgender subjectivity was constructed in their accounts and in what ways youth made use of the discursive resources available to them when navigating systems of care. Three sets of discourses-discourses of normativity, discourses of temporality, and discourse of access-characterized participants' narratives. We discuss how participants negotiated discursively situated systems of power in order to ensure their safety and access to care.

Racial and ethnic disparities in pediatric mental health

Disparities remain in mental health status and care for racial and ethnic minority youth, despite national attention to disparity reduction. This article offers a comprehensive picture of the status of pediatric disparities, by addressing the major areas affecting minority youth mental health, including: prevention of problems, need for services, access to care, mental health treatment types, and treatment outcomes. The authors address relevant factors in the family, community and socioeconomic context, and describe various local and national programs that aim to tackle the obstacles and fill the gaps in high-quality care for racial/ethnic minority youth. The article concludes by offering recommendations for improvement that acknowledge the importance of understanding preferences and attitudes toward treatment, ensuring that screening and diagnosis is appropriate to minority youth, and ensuring that evidence-based programs are available at multiple levels to best service children and succeed in addressing their needs.

Leaving no children or families outside: the challenges of immigration

This study addresses potentially stressful events that accompany the process of immigration for children and their families. Acculturation stress, combined with service disparities, may contribute to a higher risk for psychopathology among immigrant children and youth, as compared to their parents. Culturally informed, evidence-based treatment and preventive interventions that meet the mental health and cultural needs of immigrant children and families have the potential to minimize this higher risk of adverse mental health consequences.

Fear of harm, a possible phenotype of pediatric bipolar disorder: a dimensional approach to diagnosis for genotyping psychiatric syndromes

BACKGROUND

In a prior concordance study of affected sibling pairs with a community diagnosis of pediatric bipolar disorder (PBD) a behavioral phenotype termed Fear of Harm (FOH) was found to have one of the strongest concordance coefficients (rho) between probands and siblings, and the widest contrasts between the rho-estimates for the proband/sibling vs. proband/comparison pairs [Papolos, D., Hennen, J., Cockerham, M.S, Lachman, H., 2007]. A strategy for identifying phenotypic subtypes: concordance of symptom dimensions between sibling pairs who met screening criteria for a genetic linkage study of childhood-onset bipolar disorder using the Child Bipolar Questionnaire (CBQ) was employed. J. Affect. Disord. 99, 27-36.]. We used the Child Bipolar Questionnaire (OUT) (CBQ) to further elucidate this behavioral phenotype of PBD. We hypothesized that selective factors including parent reported symptoms of mania and depression, would be distinguishing features of impairment between groups defined by 1) the magnitude of their score on a continuous measure of FOH, and 2) the high FOH group would have significantly greater levels of severity on course of illness variables. These measures included earlier age of onset of first psychiatric symptoms, first hospitalization, and frequency of psychiatric hospitalizations, as well as, degree of social impairment as determined by exposure to the juvenile justice system and school performance problems.

METHODS

The sample was comprised of children with community diagnoses of bipolar disorder or at risk for the illness based on enriched family history with multiple first degree relatives diagnosed with BPD (N=5335). Included were all subjects who had >40 positively endorsed CBQ symptom items at frequencies of very often, almost always, and always. This group was divided randomly into two groups, the exploratory group (N=2668) and the hypothesis testing (study) group (N=2666). The exploratory group was used for the development of hypotheses and the study group was used to test these hypotheses on a new set of data. All results reported here derive from the latter group. In subsequent analyses, we classified each child as having a high degree of FOH, low FOH, or no FOH. We examined a subset of the sample for differences in age of onset of first psychiatric symptoms, course of illness and measures of symptom severity. These groups were compared using the chi-square procedure for categorical data and the Analysis of Variance (ANOVA) with Scheffe pair wise tests for continuous variables. The Child Bipolar Questionnaire V.2.0, the Yale-Brown Obsessive Compulsive Scale (YBOCS) and the Overt Aggression Scale (OAS) were the principal instruments used to obtain diagnostic information for this study.

RESULTS

We found that children representative of the FOH phenotype when compared to children with PBD who lack this trait had higher indices of severity of mania and depression, as well as other indices that reflect severity and course of illness. Trait factors were derived from a factor analysis of CBQ in a large population of children diagnosed with or at risk for PBD, and used to further elucidate trait features of children with FOH. Children with the FOH traits were also more likely to be defined by six CBQ factors; Sleep/Arousal, Harm to Self and Others, Territorial Aggression, Anxiety, Self-esteem, Psychosis/Parasomnias/Sweet Cravings/Obsessions (PPSO).

LIMITATIONS

This data is derived from samples enriched with bipolar disorder cases. Further validation is needed with samples in which childhood-onset BD is rarer and diagnoses more diverse. Clinician diagnosis was not validated via research interview.

CONCLUSIONS

The FOH phenotype, as defined by a metric derived from combining items from the YBOCS/OAS, is a clinically homogeneous behavioral phenotype of PBD with early age of onset, severe manic and depressive symptoms, and significant social impairment that is strongly associated with 6 CBQ factors and can be easily identified using the CBQ. Through the examination of dimensional features of PBD in an enriched sample of large size, we were able to further refine a phenotype and identify clinical dimensions potentially linked to endophenotypic markers that may prove fruitful in differential diagnosis, treatment and etiological studies of PBD. The nature of the sets of specific symptoms that comprise the FOH factors enabled us to propose a biological model for the phenotype (OUT) that involves a complex orexigenic circuit which links hypothalamic, limbic, and other brain nuclei primarily responsible for the regulation of behavioral and proposed physiological features of the FOH phenotype.

Are behavioral problems in childhood and adolescence associated with bipolar disorder in early adulthood?

Several recent studies have found an association between conduct problems and bipolar disorder in adolescents. However, prospective studies are rare and most do not apply multivariable analysis strategies to control for important variables (e.g. socio-demographics). The aim of this study was to test the association between certain conduct problems and bipolar disorders. The sample consisted of 591 adolescents (male and female) representative for 2,600 persons from the Canton of Zurich in Switzerland. Data were prospectively collected through an interviewing procedure, with the first screening taking place at the age of 19-20. The incidence rate was computed using sampling weights, and risk factors of bipolar II disorder were estimated using a multivariable logistic regression model. The 9-year incidence rate of bipolar II disorder in the canton of Zurich was 8.4% (n = 65). Adolescents and children showing behavior such as repeated running away from home and physical fighting were 2.6-3.5 times more likely to experience a bipolar II disorder than those with no indication of conduct problems. Sensitivity analysis showed that the conduct problems were not the result of low socio-economic status.

Culturally competent systems of care for children's mental health: advances and challenges

There has been a remarkable growth in cultural diversity in the United States over the past 20 years. The population of minority groups has increased at a much faster rate than the European-background population in America, and faster even among children and youth. At the same time, minority youth face increasing disparities in their mental health and in access to mental health services. These are related to the multiple challenges they already face in socioeconomic status, but are aggravated by the lack of culturally competent services that can address their specific mental health needs within the context of their culture, family, and community. This paper reviews the current knowledge about the mental health of culturally diverse youth in the United States, and provides guidance on approaches to address the disparities they face.

High rate of unrecognized bipolar mixed states among destitute Hispanic adolescents referred for "major depressive disorder"

OBJECTIVE

To ascertain the rate of bipolarity among adolescent Hispanic youths referred for the treatment of "major depressive disorder" (MDD) in a community mental health clinic (CMHC) in which the threshold for referral was moderate to severe impairment.

METHODS

The patients were 49 consecutively presenting Hispanic adolescents (33 girls and 16 boys with a range of 12-17 years), many of whom had histories of unruly, hostile and/or assaultive behavior; indeed, 1 out of 3 had been referred to the CMHC from the "First-Time Offenders Program." Upon evaluation at the CMHC triage unit, all were diagnosed as MDD rendered by a licensed paramedical mental health professional managing this unit. They were subsequently evaluated by a psychiatrist using the Structured Clinical Interview for DSM-IV.

RESULTS

Seventeen (51.5%) of the girls and 10 (62.5%) of the boys met the DSM-IV criteria for bipolar disorder. Among the bipolars, 44.4% were bipolar II and 55.6% bipolar I; 74.1%% had mixed states and 40.7% were psychotic (not mutually exclusive categories). Euphoric mania was virtually absent in this population.

LIMITATION

Data on social deviance was based on chart review. Nonetheless, given that a third had already entered the juvenile justice system upon referral validates the accuracy of characterizing this population as at least moderately impaired from the social deviance standpoint.

CONCLUSIONS

Hispanic adolescents referred with a presumptive diagnosis of MDD must be carefully assessed for the presence of occult bipolarity using a structured interview. Concurrent aggressiveness and depression should tip mental health clinicians towards bipolarity--especially mixed states. Such activated-hostile depressive (and/or manic) mixed states may in part underlie the social deviance in these patients. Given that these destitute youth are often simultaneously encountered in the juvenile justice system, undetected bipolarity among Hispanic adolescents initially regarded to have MDD represents a matter of grave public health importance. Appropriate training for mental health staff to recognize bipolar spectrum disorders in CMHCs should be mandated.

Preschool-onset mania: incidence, phenomenology and family history

OBJECTIVE

To ascertain the incidence of mania among preschool children presenting in a community mental health clinic over a 24-month period, to describe the signs and symptoms of the children meeting criteria for mania and present their family histories based on systematic diagnostic interview.

METHODS

Forty children less than the age of 5 years presented between October 2001 and September 2003. Signs of mania were determined using a structured interview. Family history was determined via live, structured interview of parents. Those meeting the criteria for major depressive disorder (MDD) or bipolar disorder (BP) were classified as having mood disorder.

RESULTS

Eleven of the 40 children (27.5%) met the criteria for mania, of which only 3 (27.3%) were mixed manic. Symptoms often included "classic" mania features (i.e. euphoric, elated mood), despite co-existing features of attention-deficit hyperactivity disorder (ADHD)--such as incessant, chaotic, even frenetic motor activation--in all of them. Seven of the 11 (63.6%) had at least one parent with BP and a total of 8 (72.7%) had a parental history of affective illness when parents with MDD were counted. One child without a first-degree relative with BP had a second degree relative with this illness. Thus, 8 of 11 (72.7%) had a relative with BP, and 9 (81.8%) a family history of mood disorder (counting both MDD and BP).

LIMITATION

Open case series.

CONCLUSION

There was a surprisingly high incidence of mania with classical features in this population. The family history data strongly support the view that these children have BP. Preschool mania appears to be strongly linked to the presence of familial affective illness. Admittedly, preschool mania is a controversial topic, and data from other centers is needed to further characterize its clinical and familial features.

Is preadolescent mania the same condition as adult mania? A British perspective

Until relatively recently, the prevailing view was that mania was uncommon in preadolescent children. In the past 15 years, however, there has been increasing interest in the idea that mania may be much more common at younger ages than previously recognized. This article is concerned with the issue of whether preadolescent mania represents the same kind of problem as adult mania. It reviews concepts of bipolar disorder and mania in adults and preadolescents, some of the issue that arise in diagnosing mania in children, and the evidence for continuities between preadolescent and adult mania. The diagnosis of mania in preadolescent children often requires that inferences are made about the meaning of some symptoms but it is not always clear that these inferences are valid. It is concluded that the extant evidence does not provide a clear conclusion about the links between preadolescent and adult mania. More work is needed on the phenomenology and diagnosis of mania in children, on its natural history and on its familial correlates.