Psychopharmacology in child and adolescent psychiatry: a review of the past seven years. Part II

Interventions for people with autism: recent advances

Autism is a pervasive and life-long disorder that is characterised by profound deficits in communication and social understanding, together with ritualistic and obsessional behaviours and a general resistance to change. Although usually associated with additional cognitive impairments (approximately 50% of those affected have an IQ below 50) the condition can occur in individuals of all levels of ability, and around 20% of cases have an IQ within the normal range. Estimates of prevalence vary from 3.3 to 16.0 per 10 000 and rates may be even higher if children within the autistic wider spectrum are included (Wing, 1993, 1996). Understanding of causation is still limited, although genetic factors are now known to play a major role (Lord & Rutter, 1994).

Bullying Mediates Between Attention-Deficit/Hyperactivity Disorder in Childhood and Psychotic Experiences in Early Adolescence

Although a childhood diagnosis of attention-deficit/hyperactivity disorder (ADHD) is known to be linked to psychotic experiences and psychotic disorders in later life, the developmental trajectories that could explain this association are unknown. Using a sample from the prospective population-based Avon Longitudinal Study of Parents and Children (ALSPAC) (N = 8247), we hypothesized that the previously reported association of ADHD combined subtype in childhood and psychotic experiences in early adolescence is mediated by traumatic events and by involvement in bullying. Moreover, we expected this mediation to be specific to ADHD and tested this by comparison with specific phobia. Children with ADHD combined subtype at age 7 were more often involved in bullying at age 10 (OR 3.635, 95% CI 1.973-6.697) and had more psychotic experiences at age 12 (OR 3.362, 95% CI 1.781-6.348). Moreover, children who were involved in bullying had more psychotic experiences (2.005, 95% CI 1.684-2.388). Bullying was a significant mediator between ADHD and psychotic experiences accounting for 41%-50% of the effect. Traumatic events from birth to age 11 were also significantly associated with ADHD combined subtype and psychotic experiences; however, there was no evidence of mediation. Specific phobia was significantly associated with psychotic experiences, but not with bullying. To conclude, bullying is a relevant translating mechanism from ADHD in childhood to psychotic experiences in early adolescence. Interventions that eliminate bullying in children with ADHD could potentially reduce the risk of having psychotic experiences in later life by up to 50%. Clinicians should thus screen for bullying in routine assessments of children with ADHD.

Clinical Characteristics and Predictors of Outcome of Schizophrenia-Spectrum Psychosis in Children and Adolescents: A Systematic Review

OBJECTIVE

Treatment of early-onset schizophrenia spectrum psychosis (EOS) is hampered by limited data on clinical presentation and illness course. We aimed to systematically review the clinical characteristics, diagnostic trajectories, and predictors of illness severity and outcomes of EOS.

METHODS

We conducted a systematic PubMed, PsycINFO, and Embase literature review including studies published from January 1, 1990 to August 8, 2014 of EOS patients with 1) ≥50% nonaffective psychosis cases; 2) mean age of subjects <19 years; 3) clinical samples recruited through mental health services; 4) cross-sectional or prospective design; 5) ≥20 participants at baseline; 6) standardized/validated diagnostic instruments; and 7) quantitative psychotic symptom frequency or severity data. Exploratory analyses assessed associations among relevant clinical variables.

RESULTS

Across 35 studies covering 28 independent samples (n = 1506, age = 15.6 years, age at illness onset = 14.5 years, males = 62.3%, schizophrenia-spectrum disorders = 89.0%), the most frequent psychotic symptoms were auditory hallucinations (81.9%), delusions (77.5%; mainly persecutory [48.5%], referential [35.1%], and grandiose [25.5%]), thought disorder (65.5%), bizarre/disorganized behavior (52.8%), and flat or blunted affect/negative symptoms (52.3%/50.4%). Mean baseline Positive and Negative Syndrome Scale (PANSS)-total, positive, and negative symptom scores were 84.5 ± 10.9, 19.3 ± 4.4 and 20.8 ± 2.9. Mean baseline Clinical Global Impressions-Severity and Children's Global Assessment Scale/Global Assessment of Functioning (CGAS/GAF) scores were 5.0 ± 0.7 and 35.5 ± 9.1. Comorbidity was frequent, particularly posttraumatic stress disorder (34.3%), attention-deficit/hyperactivity and/or disruptive behavior disorders (33.5%), and substance abuse/dependence (32.0%). Longer duration of untreated psychosis (DUP) predicted less CGAS/GAF improvement (p < 0.0001), and poor premorbid adjustment and a diagnosis of schizophrenia predicted less PANSS negative symptom improvement (p = 0.0048) at follow-up. Five studies directly comparing early-onset with adult-onset psychosis found longer DUP in EOP samples (18.7 ± 6.2 vs. 5.4 ± 3.1 months, p = 0.0027).

CONCLUSIONS

EOS patients suffer substantial impairment from significant levels of positive and negative symptoms. Although symptoms and functioning improve significantly over time, pre-/and comorbid conditions are frequent, and longer DUP and poorer premorbid adjustment is associated with poorer illness outcome.

Disrupted sensorimotor and social-cognitive networks underlie symptoms in childhood-onset schizophrenia

Schizophrenia is increasingly recognized as a neurodevelopmental disorder with altered connectivity among brain networks. In the current study we examined large-scale network interactions in childhood-onset schizophrenia, a severe form of the disease with salient genetic and neurobiological abnormalities. Using a data-driven analysis of resting-state functional magnetic resonance imaging fluctuations, we characterized data from 19 patients with schizophrenia and 26 typically developing controls, group matched for age, sex, handedness, and magnitude of head motion during scanning. This approach identified 26 regions with decreased functional correlations in schizophrenia compared to controls. These regions were found to organize into two function-related networks, the first with regions associated with social and higher-level cognitive processing, and the second with regions involved in somatosensory and motor processing. Analyses of across- and within-network regional interactions revealed pronounced across-network decreases in functional connectivity in the schizophrenia group, as well as a set of across-network relationships with overall negative coupling indicating competitive or opponent network dynamics. Critically, across-network decreases in functional connectivity in schizophrenia predicted the severity of positive symptoms in the disorder, such as hallucinations and delusions. By contrast, decreases in functional connectivity within the social-cognitive network of regions predicted the severity of negative symptoms, such as impoverished speech and flattened affect. These results point toward the role that abnormal integration of sensorimotor and social-cognitive processing may play in the pathophysiology and symptomatology of schizophrenia.

Differential neurodevelopmental trajectories in patients with early-onset bipolar and schizophrenia disorders

Schizophrenia and bipolar disorders share not only clinical features but also some risk factors such as genetic markers and childhood adversity, while other risk factors such as urbanicity and obstetric complications seem to be specific to schizophrenia. An intriguing question is whether the well-established abnormal neurodevelopment present in many children and adolescents who eventually develop schizophrenia is also present in bipolar patients. The literature on adult bipolar patients is controversial. We report data on a subgroup of patients with pediatric-onset psychotic bipolar disorder who seem to share some developmental trajectories with patients with early-onset schizophrenia. These early-onset psychotic bipolar patients have low intelligence quotient, more neurological signs, reduced frontal gray matter at the time of their first psychotic episode, and greater brain changes than healthy controls in a pattern similar to early-onset schizophrenia cases. However, patients with early-onset schizophrenia seem to have more social impairment, developmental abnormalities (eg, language problems), and lower academic achievement in childhood than early-onset bipolar patients. We suggest that some of these abnormal developmental trajectories are more related to the phenotypic features (eg, early-onset psychotic symptoms) of these 2 syndromes than to categorically defined Diagnostic and Statistical Manual of Mental Disorders disorders.

Comparative effectiveness of second-generation antipsychotic medications in early-onset schizophrenia

Scant information exists to guide pharmacological treatment of early-onset schizophrenia. We examine variation across commonly prescribed second-generation antipsychotic medications in medication discontinuation and psychiatric hospital admission among children and adolescents clinically diagnosed with schizophrenia. A 45-state Medicaid claims file (2001-2005) was analyzed focusing on outpatients, aged 6-17 years, diagnosed with schizophrenia or a related disorder prior to starting a new episode of antipsychotic monotherapy with risperidone (n = 805), olanzapine (n = 382), quetiapine (n = 260), aripiprazole (n = 173), or ziprasidone (n = 125). Cox proportional hazard regressions estimated adjusted hazard ratios of 180-day antipsychotic medication discontinuation and 180-day psychiatric hospitalization for patients treated with each medication. During the first 180 days following antipsychotic initiation, most youth treated with quetiapine (70.7%), ziprasidone (73.3%), olanzapine (73.7%), risperidone (74.7%), and aripirazole (76.5%) discontinued their medication (χ(2) = 1.69, df = 4, P = .79). Compared with risperidone, the adjusted hazards of antipsychotic discontinuation did not significantly differ for any of the 4-comparator medications. The percentages of youth receiving inpatient psychiatric treatment while receiving their initial antipsychotic medication ranged from 7.19% (aripiprazole) to 9.89% (quetiapine) (χ(2) = 0.79, df = 4, P = .94). As compared with risperidone, the adjusted hazard ratio of psychiatric hospital admission was 0.96 (95% CI: 0.57-1.61) for olanzapine, 1.03 (95% CI: 0.59-1.81) for quetiapine, 0.85 (95% CI: 0.43-1.70) for aripiprazole, and 1.22 (95% CI: 0.60-2.51) for ziprasidone. The results suggest that rapid antipsychotic medication discontinuation and psychiatric hospital admission are common in the community treatment of early-onset schizophrenia. No significant differences were detected in risk of either adverse outcome across 5 commonly prescribed second-generation antipsychotic medications.

Multicenter study of brain volume abnormalities in children and adolescent-onset psychosis

The goal of the study is to determine the extent of structural brain abnormalities in a multicenter sample of children and adolescents with a recent-onset first episode of psychosis (FEP), compared with a sample of healthy controls. Total brain and lobar volumes and those of gray matter (GM), white matter, and cerebrospinal fluid (CSF) were measured in 92 patients with a FEP and in 94 controls, matched for age, gender, and years of education. Male patients (n = 64) showed several significant differences when compared with controls (n = 61). GM volume in male patients was reduced in the whole brain and in frontal and parietal lobes compared with controls. Total CSF volume and frontal, temporal, and right parietal CSF volumes were also increased in male patients. Within patients, those with a further diagnosis of "schizophrenia" or "other psychosis" showed a pattern similar to the group of all patients relative to controls. However, bipolar patients showed fewer differences relative to controls. In female patients, only the schizophrenia group showed differences relative to controls, in frontal CSF. GM deficit in male patients with a first episode correlated with negative symptoms. Our study suggests that at least part of the GM deficit in children and adolescent-onset schizophrenia and in other psychosis occurs before onset of the first positive symptoms and that, contrary to what has been shown in children-onset schizophrenia, frontal GM deficits are probably present from the first appearance of positive symptoms in children and adolescents.

Pharmacotherapy in depressed children and adolescents

In children and adolescents, antidepressants are used in the treatment of depressive symptoms and several other psychiatric conditions. In the treatment of mild and moderate depressive symptoms, non-pharmacological approaches such as psychotherapy play a major role, a severe symptomatology may demand a combination with antidepressants. As first-choice medication for the treatment of juvenile depression, the selective serotonin reuptake inhibitor (SSRI) fluoxetine is recommended, due to its efficacy and approval. As second-choice antidepressants the SSRIs sertraline, escitalopram and citalopram might be used. Other antidepressants - such as tricyclic antidepressants, α(2)-adrenoceptor antagonists, selective noradrenalin reuptake inhibitors (SNRI) - may be alternatively used, but not as first- or second-choice medications. In the case of "off-label" use, patients and parents have to be carefully informed prior to the start of medication, after a thorough risk-benefit analysis. In the following overview we address a general framework, therapeutic strategies and the issues of antidepressant pharmacotherapy for the treatment of unipolar depression in childhood and adolescence.

Comorbidity in Pediatric Bipolar Disorder

The growing literature shows the pervasiveness and importance of comorbidity in youth with bipolar disorder (BPD). For instance, up to 90% of youth with BPD have been described to manifest comorbidity with attention-deficit hyperactivity disorder. Multiple anxiety, substance use, and disruptive behavior disorders are the other most commonly reported comorbidities with BPD. Moreover, important recent data highlight the importance of obsessive-compulsive and pervasive developmental illness in the context of BPD. Data suggest that not only special developmental relationships are operant in the context of comorbidity but also that the presence of comorbid disorders with BPD results in a more severe clinical condition. Moreover, the presence of comorbidity has therapeutic implications for the treatment response for both BPD and the associated comorbid disorder. Future longitudinal studies to address the relationship and the impact of comorbid disorders on course and therapeutic response over time are required in youth with BPD.

Pretreatment social functioning predicts 1-year outcome in early onset psychosis

OBJECTIVE

The aim was to investigate the association of pretreatment social functioning (12 months before initial presentation) with symptom dimensions and social functioning at 1-year follow-up.

METHOD

Fifty-six adolescents, age 14-18, first admitted for early onset psychosis, were evaluated at baseline and 1-year follow-up assessing psychopathology (PANSS), social functioning (Strauss and Carpenter Prognostic Scale), and duration of untreated psychosis (DUP).

RESULTS

Adolescents with low pretreatment social functioning were at risk of more severe negative symptoms and lower social functioning at follow-up. Negative symptoms at baseline were less predictive and DUP was not predictive in this sample.

CONCLUSION

Results of this study suggest a strong longitudinal inter-relatedness between social functioning and negative symptoms in this age group. An integrative treatment approach including family interventions, social skills training, long-term specialized work/school rehabilitation, and adequate antipsychotic treatment is warranted to improve both, social functioning and negative symptoms.

A comparison of divalproex and oxcarbazepine in aggressive youth with bipolar disorder

BACKGROUND

Divalproex (DVP) and oxcarbazepine (OXC) are used to treat pediatric bipolar disorder (PBPD) with severe aggression but these agents have not been compared in head to head trials.

METHODS

Electronic medical records were reviewed for those (age < 18) who received DVP (n = 20) or OXC (n = 11) for the treatment of PBPD with severe aggression. Change in prospectively rated Clinical Global Impressions-Severity (CGI-S) scores that measured global improvement of mental illness from baseline and rates of discontinuation due to adverse effects at approximately 4 months were the primary outcomes. CGI-S specific to aggression (CGI-Ag-S), which was rated retrospectively and blinded to treatment, was a secondary outcome.

RESULTS

Greater reduction in CGI-S scores occurred with DVP compared with OXC at 4 months (p = 0.007). Both CGI-S and CGI-Ag-S scores improved significantly from baseline to the 4-month timepoint with DVP but not OXC. There were no significant differences in weight changes between the groups. Rates of discontinuation due to adverse events were similar. However, more discontinuations due to worsening aggression occurred with OXC (DVP 0%, OXC 27.3%, p = 0.037). More patients receiving DVP had a decrease of 1 point or more on the CGI-S and had not discontinued due to adverse events as of the patient's last recorded visit on the index medication (DVP 13 (65%), OXC 2 (18%), p = 0.023).

CONCLUSIONS

OXC appeared less effective than DVP for PBPD with aggression in this study. Limitations included the small sample size and the open, nonrandomized, retrospective study design. Future prospective, double-blind studies are warranted to determine the place of OXC in the treatment of PBPD.

Saccadic eye movement task identifies cognitive deficits in children with schizophrenia, but not in unaffected child relatives

BACKGROUND

The delayed oculomotor response (DOR) task requires response inhibition followed by movement of gaze towards a known spatial location without a current stimulus. Abnormalities in response inhibition and in the spatial accuracy of the eye movement are found in individuals with schizophrenia and in many of their relatives, supporting the use of these saccadic abnormalities as endophenotypes in genetic studies. It is unknown whether school-age children, either with psychosis or as relatives of a schizophrenic proband, can be included.

METHOD

One hundred eighty-seven children, ages 5.8-16.0 years - 45 children with childhood-onset schizophrenia, 64 children with a first-degree relative with schizophrenia, and 84 typically developing children - completed DOR tasks with 1 and 3 second delays.

RESULTS

Children with childhood-onset schizophrenia demonstrated impaired response inhibition and impaired spatial accuracy compared to both relatives and typicals; however, relatives and typicals did not differ from each other.

CONCLUSIONS

Children with childhood-onset schizophrenia have saccadic abnormalities similar to those found in adults with schizophrenia, supporting the continuity of executive function deficits in childhood-onset with adolescent and adult-onset schizophrenia. However, saccadic tasks are not sensitive to genetic risk in non-psychotic children and 6-15-year-old children should not be included in genetic studies utilizing this endophenotype.

A 1-year open-label trial of olanzapine in school-age children with schizophrenia

OBJECTIVE

To determine the response of children with childhood-onset schizophrenia to a 1-year prospective, open-label trial of olanzapine.

METHODS

Twenty children (age range 6-15 years) with childhood-onset Diagnostic and Statistical Manual of Mental Disorders (fourth edition) schizophrenia participated. The treating clinician was free to vary or discontinue dosing and use additional medications. Symptoms were assessed by the Brief Psychiatric Rating Scale-Child version (BPRS-C), Scale for the Assessment of Positive Symptoms, and Scale for the Assessment of Negative Symptoms. Extrapyramidal symptoms, akathisia, temperature, and weight were monitored.

RESULTS

BPRS-C subscales of thought disturbance and psychomotor excitation, and the Scale for the Assessment of Positive Symptoms demonstrated significant decreases by 6 weeks of treatment; BPRS-C anxiety and the Scale for the Assessment of Negative Symptoms (SANS) showed significant improvement after 1 year of treatment. Seventy-four percent of subjects were considered treatment responders, with a greater than 20% reduction in total BPRS-C score and overall impairment of mild or better. Weight gain (body mass index) was above that expected for normal development in every child. No child developed neuroleptic-related dyskinesias. Seventy-four percent (n = 14) of patients completed this 1-year, open-label trial. Of the 5 subjects who discontinued, weight gain was noted as the reason for 4 subjects.

CONCLUSIONS

Olanzapine appears useful in the treatment of childhood-onset schizophrenia, although there may be a delayed onset of benefit for anxiety and negative symptoms. Weight gain is problematic, but the emergence of dyskinesias may be rare. Additional controlled trials are indicated.

Psychopharmacology in the Treatment of Conduct Disorder Children and Adolescents: Rationale, Prospects, and Ethics

The rationale for psychopharmacological treatments of conduct disorder (CD) in children and adolescent is discussed with reference to the presumed neurophysiological basis of the disorder. Specific psychopharmacological treatments for children with CD are identified and briefly evaluated in terms of their empirical foundations. The lack of a secure knowledge base on the biochemical basis of CD and the efficacy of psychopharmacological treatments with children and adolescents suggests the need for caution in the wide use of pharmacotherapy with these populations. Psychopharmacological treatments with children and adolescents with CD are particularly indicated for reactive aggression, and CD with comordid conditions. Conceptual and methodological improvements in use of psychotropic medications with children and adolescents are discussed as well as the associated ethical considerations.

Effective treatment for mental disorders in children and adolescents

As pressure increases for the demonstration of effective treatment for children with mental disorders, it is essential that the field has an understanding of the evidence base. To address this aim, the authors searched the published literature for effective interventions for children and adolescents and organized this review as follows: (1) prevention; (2) traditional forms of treatment, namely outpatient therapy, partial hospitalization, inpatient treatment, and psychopharmacology; (3) intensive comprehensive community-based interventions including case management, home-based treatment, therapeutic foster care, and therapeutic group homes; (4) crisis and support services; and (5) treatment for two prevalent disorders, major depressive disorder and attention-deficit hyperactivity disorder. Strong evidence was found for the treatment of attention-deficit hyperactivity disorder, depression, anxiety, and disruptive behavior disorders. Guidance from the field relevant to moving the evidence-based interventions into real-world clinical practice and further strengthening the research base will also need to address change in policy and clinical training.

Is selective mutism an anxiety disorder? Rethinking its DSM-IV classification

The relationship between selective mutism (SM) and childhood anxiety disorders is illustrated through an examination of their temperamental, environmental, and biological etiologies. SM is also explored as a symptom of the specific anxiety disorders of social phobia, separation anxiety, and posttraumatic stress disorder. The etiology and symptom overlap demonstrates SM as being an anxiety disorder or a variant of a specific anxiety disorder. The conceptualization of SM as an anxiety disorder is helpful in effectively treating afflicted children. There is enough evidence in the current literature to challenge the current classification, from the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders of SM as an Other Disorder of Infancy, Childhood, and Adolescence.

Juvenile violence

No one missing piece can solve the puzzle of juvenile violence. Although numerous risk factors have been identified, the implementation of successful preventive and treatment programs remains the greatest challenge. With children increasingly turning to gangs as substitutes for their families and using weapons to solve their problems, there is little alternative but to meet this challenge. The consequence of failing to do so is summarized by King's prophetic statement, "The choice today is no longer between violence and nonviolence. It's either nonviolence or nonexistence."

Updating What We Know About Depression in Adolescents

1. Despite an 80% increase in prescriptions written for antidepressants for the treatment of pediatric depression, little empirical research has been done on the effects of antidepressant therapy on children and adolescents. 2. What little research has been done does not support the efficacy of antidepressants use in children. Moreover, some antidepressants may actually be harmful to pediatric populations. 3. Nurses have an obligation to keep abreast of the latest research findings in the literature because the knowledge base changes daily.

Teenagers: mental health and psychological issues

Adolescence is a developmental period marked by multiple challenges and demands which create a heightened vulnerability to the development of emotional disorders. Primary care physicians are in an ideal position to intervene in the early stages and prevent the tragic consequences which can occur with an untreated mental health disorder. This article reviews the assessment and treatment of adolescent mental health in the primary care medical setting. Knowledge of these disorders and their manifestations in the primary care environment will enable clinicians to provide higher quality medical care and will reduce the potential for continual life disruptions into the adult years.

The rebellious adolescent. Evaluation and management of oppositional and conduct disorders

A wide variety of management options are available to the primary care physician who is presented with a rebellious adolescent. After a careful assessment, the clinician and other health care professionals can choose a diverse combination of interventions: individual therapy, family therapy, youth-centered programs, community-centered programs, psychopharmacology, and others. Rebellious adolescents need access to comprehensive medical and mental health care, academic education (including sexuality education), and full employment opportunities. Primary care physicians can play a vital and sometimes pivotal role coordinating services and helping parents, school personnel, and therapists work with these youth. Even when dealing with the very difficult and resistant group of youth with CD and ODD, optimism for improvement should always be maintained by the clinician.

Psychophysiological aspects of Tourette's syndrome

Tourette's syndrome (TS), once considered a rare disorder, has been investigated extensively in the last two decades. It is inherited, usually beginning in childhood, and waxes and wanes, usually decreasing in frequency and severity in adolescence and early adulthood. Pharmacotherapy is the usual treatment approach, reducing frequency and severity of symptoms, but it is not a cure and often has side effects. Psychological help for people with TS and their families may be needed for this complex disorder.

Prognosis in autism: do specialist treatments affect long-term outcome?

Many different treatments have been claimed to have a dramatic impact on children with autism. This paper reviews what is known about the outcome in adult life and examines the limitations and advantages of a variety of intervention approaches. It concludes that there is little evidence of any "cure" for autism, but appropriately structured programmes for education and management in the early years can play a significant role in enhancing functioning in later life.

Risperidone in adolescents with schizophrenia: an open pilot study

OBJECTIVE

To assess critically the short-term efficacy and safety of risperidone in adolescents with schizophrenia.

METHOD

Subjects were adolescents who were attending a research day hospital as outpatients and who had received a diagnosis of schizophrenia. This was an open pilot study; after a 2-week washout period during which all psychotropic medications were gradually discontinued, subjects were treated with risperidone for 6 weeks. Dosage was regulated individually over a period of 3 weeks; starting dose was 2.0 mg/day followed by 1.0-mg increments every 2 days; maximum dose was not to exceed 10 mg/day. The main outcome measures included the Positive and Negative Syndrome Scale of Schizophrenia, the Brief Psychiatric Rating Scale, and the Clinical Global Impression.

RESULTS

Ten adolescents between 11 and 18 years of age were enrolled in the study. Risperidone produced clinically and statistically significant improvement on the Positive and Negative Syndrome Scale for Schizophrenia. Brief Psychiatric Rating Scale, and Clinical Global Impression at doses ranging from 4.0 mg/day to 10.0 mg/day (mean = 6.6). There were no major adverse reactions associated with risperidone use.

CONCLUSIONS

Risperidone appears to have been effective and well tolerated in this sample of adolescents with schizophrenia.

Practitioner review: psychosocial treatments for conduct disorder in children

The present paper reviews promising treatments for conduct disorder among children and adolescents. The treatments include problem-solving skills training, parent management training, functional family therapy and multisystemic therapy. For each treatment, conceptual underpinnings, characteristics and outcome evidence are highlighted. Limitations associated with these treatments (e.g. paucity of long-term follow-up evidence and of evidence for the clinical significance of the change) are also presented. Broader issues that affect treatment and clinical work with conduct-disordered youths are also addressed, including retaining cases in treatment, what treatments do not work, who responds well to treatment, comorbidity, the use of combined treatments and the need for new models of treatment delivery.

Carbamazepine in aggressive children with conduct disorder: a double-blind and placebo-controlled study

OBJECTIVE

To assess critically the short-term efficacy and safety of carbamazepine in the reduction of aggressiveness in children with diagnosed conduct disorder.

METHOD

Subjects were children aged 5 to 12 years who were hospitalized for treatment-resistant aggressiveness and explosiveness and who had diagnosed conduct disorder. The study was double-blind and placebo-controlled, using a parallel-groups design. Following a 2-week placebo baseline period, children who met the aggression criteria were randomly assigned to treatments for 6 weeks; the study ended with a 1-week posttreatment placebo period. Multiple raters rated the children independently, using multiple rating scales under four conditions. The main outcome measures included the Overt Aggression Scale, the Global Clinical Judgments (Consensus) Scale, and the Children's Psychiatric Rating Scale.

RESULTS

Twenty-two children, aged 5.33 to 11.7 years, completed the study. Carbamazepine was not superior to placebo at optimal daily doses ranging from 400 to 800 mg, mean 683 mg, at serum levels of 4.98 to 9.1 micrograms/mL. Untoward effects associated with administration of carbamazepine were common.

CONCLUSIONS

In this modest sample of children, the superiority of carbamazepine over placebo in reducing aggressive behavior was not demonstrated.