1
|
Walsh KS, Mrakotsky C, Carcao M, Chan AK, Nielsen PH, Holst H, Shapiro K. Nonacog beta pegol prophylaxis in children with hemophilia B: safety, efficacy, and neurodevelopmental outcomes for up to 8 years. Res Pract Thromb Haemost 2024; 8:102341. [PMID: 38516633 PMCID: PMC10955654 DOI: 10.1016/j.rpth.2024.102341] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2023] [Revised: 12/08/2023] [Accepted: 12/12/2023] [Indexed: 03/23/2024] Open
Abstract
Background Nonacog beta pegol (N9-GP) is an extended half-life PEGylated factor (F)IX product with established efficacy and short-term safety in persons with hemophilia B (HB). Long-term safety has been evaluated for polyethylene glycol exposure but not N9-GP. Objectives To assess safety, neurodevelopmental, and efficacy outcomes of children with HB receiving N9-GP prophylaxis across 2 open-label, single-arm, phase 3 studies: paradigm5 (previously treated patients [PTPs]) and paradigm6 (previously untreated patients [PUPs]) in this interim analysis. Methods PTPs (aged ≤12 years) and PUPs (aged <6 years) with severe/moderate (≤2% FIX level) HB were recruited to N9-GP prophylaxis (40 IU/kg once weekly) in paradigm5 and paradigm6, respectively. Safety assessments included FIX inhibitor incidence, adverse events, neurocognitive and neurologic outcomes, polyethylene glycol concentration in plasma, and medical events of special interest. Efficacy endpoints included bleeds, N9-GP hemostatic effect, and FIX consumption. Results Overall, 25 patients in paradigm5 and 50 patients in paradigm6 received N9-GP and were followed for up to 8 and 6 years, respectively. No inhibitory antibodies were reported in PTPs; 4 of the 50 PUPs developed inhibitors. Extensive evaluation revealed no neurocognitive or neurologic concerns with N9-GP use in children during the study period. Across both studies, few adverse events were reported as possibly related to N9-GP. High hemostatic response rate, high treatment adherence, low annualized bleeding rates, and no new target joints were reported. Conclusion These data provide the longest follow-up for an extended half-life FIX and confirm the long-term efficacy of N9-GP prophylaxis in children with HB with no observed neurocognitive or neurologic safety concerns.
Collapse
Affiliation(s)
- Karin S. Walsh
- Center for Neuroscience and Behavioral Medicine, Children’s National Hospital and the George Washington University School of Medicine and Health Sciences, Washington, DC, USA
| | - Christine Mrakotsky
- Departments of Neurology & Psychiatry, Boston Children’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Manuel Carcao
- Division of Haematology/Oncology, Department of Paediatrics, the Hospital for Sick Children, Toronto, Ontario, Canada
| | - Anthony K.C. Chan
- Department of Paediatrics, McMaster Centre for Transfusion Research, McMaster Children’s Hospital, McMaster University, Hamilton, Ontario, Canada
| | | | | | - Kevin Shapiro
- Cortica Healthcare and Children’s Hospital Los Angeles, Westlake Village, California, USA
| |
Collapse
|
2
|
Felling RJ, Jordan LC, Mrakotsky C, deVeber G, Peterson RK, Mineyko A, Feldman SJ, Shapiro K, Lo W, Beslow LA. Roadmap for the Assessment and Management of Outcomes in Pediatric Stroke. Pediatr Neurol 2023; 141:93-100. [PMID: 36805967 DOI: 10.1016/j.pediatrneurol.2023.01.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2022] [Revised: 01/04/2023] [Accepted: 01/16/2023] [Indexed: 01/22/2023]
Abstract
Neurological morbidity is common after pediatric stroke, with moderate to severe deficits that can significantly impact education and social function. Care and recovery occur in phases distinguished by the time interval after stroke onset. These phases include the hyperacute and acute periods in which the focus is on cerebral reperfusion and prevention of neurological deterioration, followed by the subacute and chronic phases in which the focus is on secondary stroke prevention and mitigation of disability through rehabilitation, adaptation, and reintegration into the community. In this article, a multidisciplinary group of pediatric stroke experts review the stages of recovery after pediatric stroke with an emphasis on critical assessment time points. Our goal is to encourage increased standardization of outcome assessment to facilitate future clinical trials comparing various treatment and intervention options and advance optimized care for children with stroke.
Collapse
Affiliation(s)
- Ryan J Felling
- Departments of Neurology and Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland.
| | - Lori C Jordan
- Division of Pediatric Neurology, Department of Pediatrics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Christine Mrakotsky
- Departments of Psychiatry & Neurology, Center for Neuropsychology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Gabrielle deVeber
- Child Health Evaluative Sciences Program, Hospital for Sick Children Research Institute, Toronto, Ontario, Canada
| | - Rachel K Peterson
- Neuropsychology Department, Kennedy Krieger Institute, Baltimore, Maryland; Department of Psychiatry and Behavioral Sciences, Johns Hopkins University, Baltimore, Maryland
| | - Aleksandra Mineyko
- Section of Neurology, Department of Pediatrics, University of Calgary, Alberta, Canada
| | - Samantha J Feldman
- Neurosciences and Mental Health Research Program, Hospital for Sick Children Research Institute, Toronto, Ontario, Canada
| | - Kevin Shapiro
- Cortica Healthcare, Westlake Village, California; Division of Neurology, Children's Hospital Lost Angeles, Los Angeles, California
| | - Warren Lo
- Departments of Pediatrics and Neurology, The Ohio State University Nationwide Children's Hospital, Columbus, Ohio
| | - Lauren A Beslow
- Division of Neurology, Children's Hospital of Philadelphia, Departments of Neurology and Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| |
Collapse
|
3
|
Mrakotsky C, Williams TS, Shapiro KA, Westmacott R. Rehabilitation in Pediatric Stroke: Cognition and Behavior. Semin Pediatr Neurol 2022; 44:100998. [PMID: 36456041 DOI: 10.1016/j.spen.2022.100998] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2022] [Revised: 09/11/2022] [Accepted: 09/12/2022] [Indexed: 10/14/2022]
Abstract
Pediatric stroke is associated with a range of maladaptive cognitive and behavioral outcomes that often require targeted intervention. Despite increasing research on neuropsychological outcomes over the past decade, evidence for effective therapies and interventions for the most commonly reported cognitive and behavioral challenges is still limited. The most widely prescribed interventions address more overt deficits in sensorimotor and speech/language functions, yet interventions for higher-order cognitive, linguistic and behavioral deficits are notably less defined. Moreover, concepts of rehabilitation in adult stroke cannot be easily translated directly to pediatric populations because the effect of stroke and recovery in the developing brain takes a very different course than in the mature brain. In pediatric stroke, neuropsychological deficits often emerge gradually over time necessitating a long-term approach to intervention. Furthermore, family and school context often play a much larger role. The goal of this review is to describe cognitive and behavioral interventions for perinatal and childhood stroke, as motor rehabilitation is covered elsewhere in this issue. We also discuss cognitive aspects of current rehabilitative therapies and technology. Acknowledging the current limited state of stroke-specific rehabilitation research in children, findings from pediatric acquired brain injury intervention and use of transdiagnostic approaches lend important insights. Because there is limited support for single domain (cognitive) trainings and translation of research rehabilitation programs to clinical practice can be challenging, the value of holistic multidisciplinary approaches to improve everyday function in children and adolescents following stroke is emphasized.
Collapse
Affiliation(s)
- Christine Mrakotsky
- Departments of Neurology & Psychiatry, Boston Children's Hospital, Harvard Medical School, Boston, MA.
| | - Tricia S Williams
- Department of Psychology, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Kevin A Shapiro
- Cortica Healthcare, Department of Neurology, Children's Hospital Los Angeles, Los Angeles, CA
| | - Robyn Westmacott
- Department of Psychology, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| |
Collapse
|
4
|
Krivitzky LS, Westmacott R, Boada R, Sepeta L, Reppert L, Mrakotsky C. Recent Advances in Neuropsychological Outcomes and Intervention in Pediatric Stroke. Stroke 2022; 53:3780-3789. [DOI: 10.1161/strokeaha.122.037294] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Over the past 15 years, there have been significant advances in the treatment of acute and chronic medical consequences of stroke in childhood. Given high rates of survival in pediatric stroke, practitioners are tasked with treating the ongoing motor and neuropsychological sequelae in patients over the course of their development. This article provides a review of the current literature on neuropsychological outcomes in pediatric stroke, including intelligence, academics, language, visual-spatial skills, attention, executive functions, memory, and psychosocial function. Recent developments in functional neuroimaging are discussed, with a particular focus on language outcomes. We further review the current research on cognitive and behavioral rehabilitation and introduce intervention models in pediatric stroke. In the final section, we discuss future directions for clinical practice and research in pediatric stroke.
Collapse
Affiliation(s)
- Lauren S. Krivitzky
- Department of Child and Adolescent Psychiatry and Behavioral Sciences, Children’s Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine (L.S.K.)
| | - Robyn Westmacott
- Department of Psychology, The Hospital for Sick Children, University of Toronto, Canada (R.W.)
| | - Richard Boada
- Division of Neurology, Children’s Hospital Colorado, University of Colorado School of Medicine, Aurora (R.B.)
| | - Leigh Sepeta
- Division of Neuropsychology, Children’s National Hospital, Washington, DC. (L.S.)
| | - Lauren Reppert
- Division of Neurology, Children’s National Hospital, Washington, DC. (L.R.)
| | - Christine Mrakotsky
- Departments of Psychiatry and Neurology, Boston Children’s Hospital, Harvard Medical School, MA (C.M.)
| |
Collapse
|
5
|
Bearden DJ, Waber DP, Schreiber J, Mrakotsky C. Functional abdominal pain symptom severity: Associations between cognition and emotion in a pediatric sample. Appl Neuropsychol Child 2022; 11:69-80. [PMID: 32538220 PMCID: PMC8589105 DOI: 10.1080/21622965.2020.1758106] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Functional abdominal pain (FAP) is a common physical complaint in children and adolescents. Prior research has documented associations between FAP symptoms and mood, especially internalizing behaviors. Limited research is available examining the association between symptom burden and cognitive function in this pediatric population. This study explored associations between FAP symptoms, internalizing behaviors, and cognitive and school function in children and adolescents. Twenty-seven participants (mean age = 12.6 years, range 8.8-16.5; 33% male) diagnosed with FAP completed assessments of cognitive, emotional, and behavioral function, as well as FAP symptom severity. Mean performances on cognitive tests were within age-expected ranges. Within this context, however, higher overall burden of FAP symptoms was associated with slower processing speed, more self-reported metacognitive problems and internalizing behaviors, and more school absences. Cognitive function was systematically associated with internalizing behaviors but not physical symptoms. Overall, findings revealed that FAP may be associated with cognitive inefficiencies in addition to internalizing problems. Cognitive symptoms may be linked to internalizing behaviors associated with FAP.
Collapse
Affiliation(s)
- Donald Jay Bearden
- Boston Children’s Hospital, Neuropsychology, Boston, 02115-5724 United States,Children’s Healthcare of Atlanta Inc, Neuropsychology, Atlanta, 30329-2303 United States
| | | | - Jane Schreiber
- Children’s Hospital of Philadelphia Pediatrics Residency Program, Philadelphia, 19104 United States
| | | |
Collapse
|
6
|
Lehman LL, Bruccoleri R, Danehy A, Swanson J, Mrakotsky C, Smith E, Orbach DB, Burstein R. Adverse effects of erenumab on cerebral proliferative angiopathy: A case report. Cephalalgia 2020; 41:122-126. [PMID: 32814432 DOI: 10.1177/0333102420950484] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND Cerebral proliferative angiopathy is a vascular malformation associated with compromised blood-brain barrier and with migraine-like headache. Treating blood-brain barrier-compromised patients with erenumab, an anti-calcitonin gene-related peptide receptor monoclonal antibody, may be risky. CASE We describe a case of a 22-year-old chronic migraine patient with cerebral proliferative angiopathy who presented to our hospital in status epilepticus 2 d after his first dose of erenumab. Serial magnetic resonance imaging (MRI) studies demonstrated progressive areas of diffusion restriction including the brain tissue adjacent to the cerebral proliferative angiopathy, bilateral white matter and hippocampi. His 6-month post-presentation magnetic resonance imaging was notable for white matter injury, encephalomalacia surrounding cerebral proliferative angiopathy and bilateral hippocampal sclerosis. He remains clinically affected with residual symptoms, including refractory epilepsy and cognitive deficits. CONCLUSION The evidence presented in this case supports further investigation into potential deleterious side effects of erenumab in patients with compromised blood-brain barrier, such as individuals with intracranial vascular malformations.
Collapse
Affiliation(s)
- Laura L Lehman
- Department of Neurology, Boston Children's Hospital, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
| | - Rebecca Bruccoleri
- Department of Pediatrics, Boston Children's Hospital, Boston, MA, USA.,Department of Medicine, Vanderbilt University, Nashville, TN, USA
| | - Amy Danehy
- Harvard Medical School, Boston, MA, USA.,Department of Radiology, Boston Children's Hospital, Boston, MA, USA
| | - Julie Swanson
- Department of Neurology, Boston Children's Hospital, Boston, MA, USA
| | - Christine Mrakotsky
- Department of Neurology, Boston Children's Hospital, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA.,Department of Psychiatry, Boston Children's Hospital, Boston, MA, USA
| | - Edward Smith
- Harvard Medical School, Boston, MA, USA.,Department of Neurosurgery, Boston Children's Hospital, Boston, MA, USA
| | - Darren B Orbach
- Harvard Medical School, Boston, MA, USA.,Department of Radiology, Boston Children's Hospital, Boston, MA, USA
| | - Rami Burstein
- Harvard Medical School, Boston, MA, USA.,Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Hospital, Boston, MA, USA
| |
Collapse
|
7
|
Lehman LL, Maletsky K, Beaute J, Rakesh K, Kapur K, Rivkin MJ, Mrakotsky C. Prevalence of Symptoms of Anxiety, Depression, and Post-traumatic Stress Disorder in Parents and Children Following Pediatric Stroke. J Child Neurol 2020; 35:472-479. [PMID: 32202201 DOI: 10.1177/0883073820909617] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Post-traumatic stress disorder (PTSD), anxiety, and depression are seen in parents and children following critical illness. Whether this exists in parents and children following pediatric stroke has not been thoroughly studied. We examined emotional outcomes in 54 mothers, 27 fathers, and 17 children with stroke. Parents of children 0-18 years and children 7-18 years who were within 2 years of stroke occurrence were asked to complete questionnaires to determine their emotional outcomes. Of participating mothers, 28% reported PTSD, 26% depression, and 4% anxiety; in fathers, 15% reported PTSD, 24% depression, and none reported anxiety. Further, children reported significant emotional difficulty, with 24% having depression, 14% anxiety, and 6% PTSD by self-report ratings. Maternal PTSD, anxiety and depression, and paternal anxiety were all negatively associated with the child's functional outcome. Clinically significant anxiety (based on clinical thresholds) was not found in fathers; however, continuous scores were still analyzed for association between subclinical anxiety and functional outcome, which revealed a statistically significant association between more reported symptoms and higher Recovery and Recurrence Questionnaire scores. Prevalence of PTSD and depression are greater in parents compared to the general population in this preliminary study.
Collapse
Affiliation(s)
- Laura L Lehman
- Department of Neurology, Boston Children's Hospital, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
| | - Kristin Maletsky
- Department of Neurology, Boston Children's Hospital, Boston, MA, USA
| | - Jeanette Beaute
- Department of Neurology, Boston Children's Hospital, Boston, MA, USA
| | - Kshitiz Rakesh
- Department of Neurology, Boston Children's Hospital, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
| | - Kush Kapur
- Department of Neurology, Boston Children's Hospital, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
| | - Michael J Rivkin
- Department of Neurology, Boston Children's Hospital, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA.,Department of Psychiatry, Boston Children's Hospital, Boston, MA, USA.,Department of Radiology Boston Children's Hospital, Boston, MA, USA
| | - Christine Mrakotsky
- Department of Neurology, Boston Children's Hospital, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA.,Department of Psychiatry, Boston Children's Hospital, Boston, MA, USA
| |
Collapse
|
8
|
Buranahirun C, Walsh KS, Mrakotsky C, Croteau SE, Rajpurkar M, Kearney S, Hannemann C, Wilkening GN, Shapiro KA, Cooper DL. Neuropsychological function in children with hemophilia: A review of the Hemophilia Growth and Development Study and introduction of the current eTHINK study. Pediatr Blood Cancer 2020; 67:e28004. [PMID: 31595670 DOI: 10.1002/pbc.28004] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2019] [Revised: 08/12/2019] [Accepted: 08/16/2019] [Indexed: 11/12/2022]
Abstract
Almost all of what is known about neurologic and cognitive development in hemophilia derives from the Hemophilia Growth and Development Study, conducted during an era when treatment regimens and comorbidities differed significantly from the current environment. Results suggested hemophilia and human immunodeficiency virus had independent effects, and hemophilia negatively impacts academic achievement, attention, and behavior. The introduction of prophylaxis treatment in hemophilia has created the need for re-evaluation of the effects of hemophilia on neurodevelopment and cognition. We outline the Evolving Treatment of Hemophilia's Impact on Neurodevelopment, Intelligence, and Other Cognitive Functions (NCT03660774) study, which aims to meet this need.
Collapse
Affiliation(s)
- Cathy Buranahirun
- Keck School of Medicine, University of Southern California/Children's Hospital Los Angeles, Los Angeles, California
| | - Karin S Walsh
- Children's National Health System, Washington, District of Columbia
| | - Christine Mrakotsky
- Division of Hematology-Oncology, Boston Children's Hospital/Harvard Medical School, Boston, Massachusetts
| | - Stacy E Croteau
- Division of Hematology-Oncology, Boston Children's Hospital/Harvard Medical School, Boston, Massachusetts
| | - Madhvi Rajpurkar
- Carman and Ann Adams Department of Pediatrics, Children's Hospital of Michigan/Wayne State University, Detroit, Michigan
| | | | - Cara Hannemann
- Indiana Hemophilia and Thrombosis Center, Indianapolis, Indiana
| | - Greta N Wilkening
- Department of Pediatrics, Children's Hospital Colorado, Aurora, Colorado
| | | | | |
Collapse
|
9
|
Lehman LL, Maletsky K, Islam F, Rivkin MJ, Mrakotsky C. Abstract T P363: A Pilot Study: Parents Show Evidence of PTSD while Children Display Anxiety following Childhood Stroke. Stroke 2015. [DOI: 10.1161/str.46.suppl_1.tp363] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Objectives:
Post-traumatic stress disorder (PTSD) is commonly found in parents and child following life-threatening pediatric illness or injury including cancer, organ transplant, traumatic brain injury, and admission to the pediatric intensive care unit. It can be diagnosed months to years after the event. The prevalence and significance of PTSD in parents and children following a childhood stroke are unknown. We examine the emotional outcomes of a cohort of 33 parents and 10 children following recent stroke in the child.
Methods:
We prospectively enrolled children with stroke of ages 7-18 years and parents of children with stroke ages 0-18 years whose stroke occurred in 2013 or 2014. Parents were screened for PTSD using the PTSD checklist and children with stroke ≥ 7 years of age were screened with the University of California Los Angeles PTSD Reaction Index. Emotional outcome of the child was examined with the Behavior Assessment System for Children (BASC-2). Parents were surveyed on their child’s stroke outcome with the Recurrence and Recovery Questionnaire (RRQ).
Results:
Of the 33 parents (10 fathers, 23 mothers) 18 (55%) met one or more of the 3 PTSD criteria and 8 (24%) met all criteria for PTSD. Although not yet reaching significance, RRQ is higher in the group of parents with PTSD (RRQ M= 1.2, SD=1.4) compared to parents without PTSD (M=0.6, SD=1.0). The subsample of children enrolled ranged in age from 7 to 17 years old at time of stroke. Although preliminary, of the children who were surveyed none met criteria for PTSD while 2 of the 9 (22%) had clinically significant levels of anxiety.
Conclusion:
Preliminary findings reveal a rate of PTSD in parents of children with childhood stroke similar to that found in parents of other critically ill children. We did not yet detect PTSD in our small sample of children. However, emotional ratings revealed that over 20% experience anxiety. The children of parents with PTSD had higher RRQ scores reflecting increased disability which may be related to the parent’s PTSD. PTSD in parents of a child with stroke and children with anxiety following stroke could impede compliance with therapeutic interventions and, consequently, lead to poorer functional outcome in the child.
Collapse
|
10
|
Abstract
PURPOSE OF REVIEW Depression in pediatric inflammatory bowel disease is increasingly recognized to be a heterogeneous condition with diverse underlying predisposing and precipitating factors. Although there is a growing awareness regarding the benefits of integrating behavioral health into medical care, the way psychiatric treatments can best target different aspects of depression and related dysfunction has not been systematically explored. RECENT FINDINGS This review discusses neurobiological risk factors for depression in inflammatory bowel disease including inflammation, associated anti-inflammatory treatment with corticosteroids, pain, and sleep disturbance, as well as psychosocial factors including reactions to illness, illness perception, and disease and environmental stressors with an emphasis on how these factors can influence treatment decisions. Empirically supported psychosocial and psychopharmacological interventions are discussed within this context. SUMMARY Understanding the diverse pathways that can lead to depression in youths with inflammatory bowel disease can lead to the development of more targeted interventions and better integration of psychosocial care into the medical treatment of inflammatory bowel disease.
Collapse
Affiliation(s)
| | | | - Eva Szigethy
- University of Pittsburgh, Department of Psychiatry
| |
Collapse
|
11
|
Gonzalez-Heydrich J, Hsin O, Gumlak S, Kimball K, Rober A, Azeem MW, Hickory M, Mrakotsky C, Torres A, Mezzacappa E, Bourgeois B, Biederman J. Comparing stimulant effects in youth with ADHD symptoms and epilepsy. Epilepsy Behav 2014; 36:102-7. [PMID: 24907495 PMCID: PMC4109643 DOI: 10.1016/j.yebeh.2014.04.026] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2014] [Revised: 04/01/2014] [Accepted: 04/29/2014] [Indexed: 11/19/2022]
Abstract
To retrospectively examine response to stimulant treatment in patients with epilepsy and ADHD symptoms as predicted by seizure freedom for six months, use of methylphenidate (MPH) versus amphetamine (AMP) preparations, cognitive level, and medical records were searched for patients under the age of 18 with epilepsy and ADHD symptoms treated with MPH or AMP (n=36, age=10.4 ± 3.5; male=67%). "Responders" had a CGI-improvement score of ≤ 2 and did not stop medication because of adverse effects. "Worsened" patients discontinued medication because of agitation/emotional lability. Seizure freedom did not predict treatment response. Lower cognitive level was associated with increased rate of worsening (p=0.048). No patients who were seizure-free at the start of the medication trial experienced an increase in seizures. Of the patients having seizures at the start of trial, one patient on MPH and two patients on AMP had increased seizures during the trial. Seizures returned to baseline frequency or less after stimulant discontinuation or anticonvulsant adjustment. Methylphenidate was associated with a higher response rate, with 12 of 19 given MPH (0.62 ± 0.28 mg/kg/day) compared with 4 of 17 given AMP (0.37 ± 0.26 mg/kg/day) responding (p=0.03). Methylphenidate treatment and higher cognitive level were associated with improved treatment outcome, while seizure freedom had no clear effect. Confidence in these findings is limited by the study's small, open-label, and uncontrolled design.
Collapse
Affiliation(s)
| | - Olivia Hsin
- Department of Psychiatry, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Sarah Gumlak
- Department of Psychiatry, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Kara Kimball
- Department of Psychiatry, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Ashley Rober
- Department of Psychiatry, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | | | | | - Christine Mrakotsky
- Department of Psychiatry, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Alcy Torres
- Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Enrico Mezzacappa
- Department of Psychiatry, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Blaise Bourgeois
- Department of Epilepsy & Clinical Neurophysiology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Joseph Biederman
- Department of Psychiatry, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| |
Collapse
|
12
|
Thompson RD, Craig AE, Mrakotsky C, Bousvaros A, DeMaso DR, Szigethy E. Using the Children's Depression Inventory in youth with inflammatory bowel disease: support for a physical illness-related factor. Compr Psychiatry 2012; 53:1194-9. [PMID: 22682678 PMCID: PMC4017927 DOI: 10.1016/j.comppsych.2012.04.006] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2011] [Revised: 03/21/2012] [Accepted: 04/18/2012] [Indexed: 11/26/2022] Open
Abstract
The objective of the present investigation was to evaluate the factor structure of the Children's Depression Inventory (CDI) in adolescents with inflammatory bowel disease (IBD) to better understand the CDI's psychometric properties in a medically complicated population. An exploratory factor analysis was performed on CDI data collected from a clinical sample of 191 youth with IBD, aged 11 to 17 years. Exploratory factor analysis with quartimax rotation yielded 3 factors: mood, behavioral/motivational, and somatic complaints. Only the somatic factor (ie, fatigue, sleep, decreased appetite, and worry about aches and pain) showed a significant positive correlation with IBD severity. The CDI holds promise as a brief measure for the assessment of depressive features psychometrically independent of IBD severity and common steroid treatments as well as of nongastrointestinal specific somatic complaints in a sample of adolescents with IBD. Continued work in this area of research appears promising in honing the assessment of depressive and somatic symptoms in youths with IBD.
Collapse
Affiliation(s)
- Rachel D. Thompson
- Departments of Psychiatry and Pediatrics, Children’s Hospital of Pittsburgh, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, U.S.A
| | - Anna E. Craig
- Department of Psychology, University of Pittsburgh, Pittsburgh, Pennsylvania, U.S.A
| | - Christine Mrakotsky
- Departments of Psychiatry and Pediatrics, Children’s Hospital Boston, Harvard Medical School, Boston, Massachusetts, U.S.A
| | - Athos Bousvaros
- Departments of Psychiatry and Pediatrics, Children’s Hospital Boston, Harvard Medical School, Boston, Massachusetts, U.S.A
| | - David R. DeMaso
- Departments of Psychiatry and Pediatrics, Children’s Hospital Boston, Harvard Medical School, Boston, Massachusetts, U.S.A
| | - Eva Szigethy
- Departments of Psychiatry and Pediatrics, Children’s Hospital of Pittsburgh, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, U.S.A
| |
Collapse
|
13
|
Gonzalez-Heydrich J, Whitney J, Waber D, Forbes P, Hsin O, Faraone SV, Dodds A, Rao S, Mrakotsky C, MacMillan C, DeMaso DR, de Moor C, Torres A, Bourgeois B, Biederman J. Adaptive phase I study of OROS methylphenidate treatment of attention deficit hyperactivity disorder with epilepsy. Epilepsy Behav 2010; 18:229-37. [PMID: 20493783 PMCID: PMC2902631 DOI: 10.1016/j.yebeh.2010.02.022] [Citation(s) in RCA: 59] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2009] [Revised: 02/23/2010] [Accepted: 02/26/2010] [Indexed: 11/26/2022]
Abstract
OBJECTIVE The goal of this study was to pilot a randomized controlled trial of OROS methylphenidate (OROS-MPH) to treat attention deficit hyperactivity disorder (ADHD) plus epilepsy. METHODS Thirty-three patients, 6-18years of age, taking antiepileptic drugs and with a last seizure 1-60months prior were assigned to a maximum daily dose of 18, 36, or 54mg of OROS-MPH in a double-blind placebo-controlled crossover trial. RESULTS There were no serious adverse events and no carryover effects in the crossover trial. OROS-MPH reduced ADHD symptoms more than did placebo treatment. There were too few seizures during the active (5) and placebo arms (3) to confidently assess seizure risk; however, considering exposure time, we observed an increased daily risk of seizures with increasing dose of OROS-MPH, suggesting that potential safety concerns require further study. CONCLUSION A larger study to assess the effect of OROS-MPH on seizure risk is needed. A crossover design including subjects with frequent seizures could maximize power and address high patient heterogeneity and recruitment difficulties.
Collapse
Affiliation(s)
- Joseph Gonzalez-Heydrich
- Department of Psychiatry, Children's Hospital Boston, Harvard Medical School, Boston, MA 02115, USA.
| | - Jane Whitney
- Department of Psychiatry, Children’s Hospital Boston, Harvard Medical School, Boston, MA
| | - Deborah Waber
- Department of Psychiatry, Children’s Hospital Boston, Harvard Medical School, Boston, MA
| | - Peter Forbes
- Clinical Research Program, Children’s Hospital Boston, Boston, MA
| | - Olivia Hsin
- Department of Psychiatry, Children’s Hospital Boston, Harvard Medical School, Boston, MA
| | - Stephen V. Faraone
- Medical Genetics Research and Department of Psychiatry, SUNY Upstate Medical University, Syracuse, NY
| | - Alice Dodds
- Department of Psychiatry, Children’s Hospital Boston, Harvard Medical School, Boston, MA
| | - Sneha Rao
- Department of Psychiatry, Children’s Hospital Boston, Harvard Medical School, Boston, MA
| | - Christine Mrakotsky
- Department of Psychiatry, Children’s Hospital Boston, Harvard Medical School, Boston, MA
| | - Carlene MacMillan
- Department of Psychiatry, Children’s Hospital Boston, Harvard Medical School, Boston, MA
| | - David R. DeMaso
- Department of Psychiatry, Children’s Hospital Boston, Harvard Medical School, Boston, MA
| | - Carl de Moor
- Department of Psychiatry, Children’s Hospital Boston, Harvard Medical School, Boston, MA, Clinical Research Program, Children’s Hospital Boston, Boston, MA
| | - Alcy Torres
- Department of Neurology, Children’s Hospital Boston, Harvard Medical School, Boston, MA
| | - Blaise Bourgeois
- Department of Neurology, Children’s Hospital Boston, Harvard Medical School, Boston, MA
| | - Joseph Biederman
- Pediatric Psychopharmacology Research Unit, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| |
Collapse
|
14
|
Mrakotsky C, Masek B, Biederman J, Raches D, Hsin O, Forbes P, de Moor C, DeMaso DR, Gonzalez-Heydrich J. Prospective open-label pilot trial of mirtazapine in children and adolescents with social phobia. J Anxiety Disord 2008; 22:88-97. [PMID: 17419001 DOI: 10.1016/j.janxdis.2007.01.005] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2006] [Revised: 12/22/2006] [Accepted: 01/26/2007] [Indexed: 11/30/2022]
Abstract
Mirtazapine is indicated for major depression and used for anxiety in adults; however, little is known about its application in pediatric populations. This is an 8-week open-label pilot study of mirtazapine in children with social phobia age 8-17 years. Primary outcomes were symptom improvement based on clinician rating and self-report, as well as tolerability based on rates of discontinuation due to adverse effects. Fifty-six percent (10/18) responded to treatment, 17% (3/18) achieved full remission. Social phobia symptoms improved significantly during the first 2 weeks of treatment, as did comorbid symptoms of depression and anxiety. Eleven patients (61%) did not complete all 8 weeks of treatment; four patients (22%) discontinued due to adverse effects including fatigue and irritability. The others discontinued due to study burden (28%), insufficient response (6%), or to pursue herbal treatment (6%). Significant weight gain was observed. Larger controlled trials are needed to further evaluate efficacy and safety.
Collapse
Affiliation(s)
- Christine Mrakotsky
- Department of Psychiatry, Children's Hospital Boston, 300 Longwood Avenue, Fegan 8, Boston, MA 02115, United States
| | | | | | | | | | | | | | | | | |
Collapse
|
15
|
Gonzalez-Heydrich J, Dodds A, Whitney J, MacMillan C, Waber D, Faraone SV, Boyer K, Mrakotsky C, DeMaso D, Bourgeois B, Biederman J. Psychiatric disorders and behavioral characteristics of pediatric patients with both epilepsy and attention-deficit hyperactivity disorder. Epilepsy Behav 2007; 10:384-8. [PMID: 17368109 PMCID: PMC1925048 DOI: 10.1016/j.yebeh.2007.01.010] [Citation(s) in RCA: 52] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2006] [Revised: 01/25/2007] [Accepted: 01/26/2007] [Indexed: 12/01/2022]
Abstract
OBJECTIVE Attention-deficit hyperactivity disorder (ADHD) coexisting with epilepsy is poorly understood; thus, we compared the clinical correlates and psychiatric comorbid conditions of 36 children with epilepsy and ADHD aged 6 to 17 years enrolled in an ADHD treatment trial, with those reported in the literature on children with ADHD without epilepsy. METHODS Measures included the Kiddie Schedule for Affective Disorders and Schizophrenia for School-Age Children (KSADS), the Wechsler Abbreviated Scale of Intelligence (WASI), and the Scales for Independent Behavior-Revised (SIB-R). RESULTS Mean IQ was 86+/-19, and SIB-R Standard Score was 72+/-26. The ADHD-Combined subtype, composed of both inattentive and hyperactive symptoms, was most frequent (58%). Sixty-one percent exhibited a comorbid disorder, including anxiety disorders (36%) and oppositional defiant disorder (31%). CONCLUSIONS Comorbidity in ADHD with epilepsy is similar to that in ADHD without epilepsy reported in the literature. These preliminary data argue that the pathophysiology of ADHD has common components in both populations.
Collapse
Affiliation(s)
- Joseph Gonzalez-Heydrich
- Psychopharmacology Program, Children's Hospital Boston, Harvard Medical School, Boston, MA 02115, USA.
| | | | | | | | | | | | | | | | | | | | | |
Collapse
|
16
|
Luby J, Mrakotsky C, Stalets MM, Belden A, Heffelfinger A, Williams M, Spitznagel E. Risperidone in preschool children with autistic spectrum disorders: an investigation of safety and efficacy. J Child Adolesc Psychopharmacol 2006; 16:575-87. [PMID: 17069546 DOI: 10.1089/cap.2006.16.575] [Citation(s) in RCA: 104] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
INTRODUCTION Early intervention in autism spectrum disorders (ASDs) appears promising and may represent a window of opportunity for more effective treatment. Whereas the safety and efficacy of risperidone have been established for children aged 5 and older, they has not been adequately tested in preschool children. METHODS A randomized placebo-controlled study of risperidone in preschool children was conducted in a sample of young children, most of whom were also undergoing intensive behavioral treatment. RESULTS Preschool children tolerated low-dose risperidone well with no serious adverse effects observed over a 6-month treatment period. Weight gain and hypersalivation were the most common side effects reported, and hyperprolactinemia without lactation or related signs was observed. Significant differences between groups found at baseline complicated the analyses; however, controlling for some of these differences revealed that preschoolers on risperidone demonstrated greater improvements in autism severity. The change in autism severity scores from baseline to 6-month follow up for the risperidone group was 8% compared to 3% for the placebo group. Notably, both groups significantly improved over the 6-month treatment period. CONCLUSIONS Study findings suggest that risperidone is well tolerated in preschoolers over a 6-month period, but that only minimally greater improvement in target symptoms was evident in the risperidone group, possibly due to the differences between groups at baseline or due to the small sample size. Although these findings are not sufficient to direct treatment, they suggest that larger-scale, double-blind, placebo-controlled investigations of risperidone in preschoolers with ASDs should now be conducted.
Collapse
Affiliation(s)
- Joan Luby
- Department of Psychiatry, Washington University School of Medicine, St. Louis, Missouri 63117, USA.
| | | | | | | | | | | | | |
Collapse
|
17
|
Luby JL, Mrakotsky C, Heffelfinger A, Brown K, Spitznagel E. Characteristics of depressed preschoolers with and without anhedonia: evidence for a melancholic depressive subtype in young children. Am J Psychiatry 2004; 161:1998-2004. [PMID: 15514399 DOI: 10.1176/appi.ajp.161.11.1998] [Citation(s) in RCA: 96] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE This study investigated whether a melancholic subtype similar to that established in depressed adults can be identified in depressed preschool children. METHOD A final group total of 156 preschool children between the ages of 3.0 and 5.6 years and their caregivers underwent a comprehensive psychiatric assessment that included a structured psychiatric interview modified for young children. The clinical characteristics of four study groups (N=156) were compared: depressed preschoolers with anhedonia, depressed preschoolers without anhedonia ("hedonic"), a psychiatric comparison group with DSM-IV attention deficit hyperactivity disorder and/or oppositional defiant disorder, and a healthy comparison group. RESULTS Fifty-four depressed preschoolers were identified, and 57% of this depressed group was anhedonic, a symptom deemed to be highly developmentally and clinically significant when arising in the preschool period. The anhedonic depressed subgroup identified was characterized by greater depression severity, alterations in stress cortisol reactivity, increased family history of major depressive disorder, and increased frequency of psychomotor retardation as well as other melancholic symptoms, such as a lack of brightening in response to joyful events. CONCLUSIONS The clinical characteristics of this depressed subgroup are consistent with those described in melancholic depressed adults and suggest that a melancholic depressed subtype can be manifest in children as young as age 3.
Collapse
Affiliation(s)
- Joan L Luby
- Department of Psychiatry, Washington University School of Medicine, 660 S. Euclid Ave., Box 8134, St. Louis, MO 63110, USA.
| | | | | | | | | |
Collapse
|
18
|
Luby JL, Heffelfinger A, Mrakotsky C, Brown K, Hessler M, Spitznagel E. Alterations in stress cortisol reactivity in depressed preschoolers relative to psychiatric and no-disorder comparison groups. ACTA ACUST UNITED AC 2004; 60:1248-55. [PMID: 14662557 DOI: 10.1001/archpsyc.60.12.1248] [Citation(s) in RCA: 149] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
BACKGROUND Despite the robust and widely replicated finding of elevated hypothalamic-pituitary-adrenal (HPA) axis reactivity in depressed adults, studies of depressed children have yielded ambiguous findings. Animal models of early depression and studies of children experiencing early psychosocial deprivation have suggested that alterations in HPA axis reactivity are evident in early "depressive-like" conditions. The current study is, to our knowledge, the first investigation of HPA axis reactivity in very young children with a clinical depressive syndrome for which content validity has been established. METHODS Depressed, psychiatric, and no-disorder comparison children aged 3 through 5.6 years were studied for HPA axis reactivity in response to experimental psychosocial stressors. The children were diagnosed using a developmentally appropriate, structured psychiatric interview. Salivary cortisol was obtained at 3 time points during a laboratory assessment before and after stressors involving separation from the parent and frustrating tasks. RESULTS Repeated measures of multivariate analysis of variance revealed a significant interaction between the diagnostic group and 2 cortisol percent change scores. Depressed preschoolers displayed a pattern of increasing cortisol levels throughout the assessment in response to both separation and frustration stressors. In contrast, both comparison groups showed decreasing cortisol levels in response to the separation stressor. All groups displayed increasing cortisol levels in response to frustrating tasks. Preschoolers with a presumptive melancholic depressive subtype displayed these alterations at a greater magnitude relative to comparison groups. CONCLUSIONS To our knowledge, these findings are the first to demonstrate altered HPA axis reactivity in depressed preschoolers. These alterations are consistent with those described in depressed adults and in animal models of early depression. These findings provide evidence for possible continuity of HPA axis alterations in depressive disorders across the lifespan and are discussed in the context of prior studies of HPA axis reactivity in clinically depressed children and adolescents, suggesting that younger age and inpatient status are features associated with altered HPA axis reactivity.
Collapse
Affiliation(s)
- Joan L Luby
- Washington University School of Medicine, Department of Psychiatry, St Louis, MO 63110, USA.
| | | | | | | | | | | |
Collapse
|
19
|
Abstract
Earlier age of onset of an episode of depression and family history of bipolar disorder (FHBPD) are well known to be associated with increased rates of switching to mania in childhood major depressive disorder (MDD). These findings suggest that the youngest samples of depressed children who have FHBPD might be at very high risk for switching. The finding of a valid depressive syndrome in preschool children has raised the question of whether mania could also manifest at this early stage. We investigated FHBPD among three preschool study groups: a depressed group and two nondepressed comparison groups (attention deficit hyperactivity disorder/oppositional defiant disorder, no disorder). Increased FHBPD was found among the depressed group. Based on this, we explored whether the depressed subgroup with FHBPD (MDD + FHBPD) had a unique constellation of depressive symptoms compared to the depressed subgroup without FHBPD (MDD with no FHBPD). The MDD + FHBPD group was found to have an increased frequency of the MDD symptom of "restlessness and moves around a lot" as compared with the MDD with no FHBPD group. The question of whether this symptom could be an early precursor of later mania was explored. These findings taken together suggest that early risk factors for switching to mania may be present in a subgroup of depressed preschoolers. Longitudinal follow-up of depressed preschool samples to determine rates of switching to mania later in development is critical to determine whether such findings represent early risk factors. Future studies that directly investigate age-appropriate mania manifestations in preschool samples are now warranted.
Collapse
Affiliation(s)
- Joan L Luby
- Washington University School of Medicine, St. Louis, Missouri 63110, USA.
| | | |
Collapse
|
20
|
Abstract
OBJECTIVE This study compared the severity of depression in preschoolers diagnosed by standard versus modified DSM-IV criteria for major depression. METHOD A group of 145 preschoolers and their caregivers underwent a diagnostic assessment for preschool children. A factor analysis of depressive symptoms from the group was performed to derive a depression severity score. Scores were compared among four groups: standard DSM-IV major depression, modified DSM-IV major depression, DSM-IV attention deficit hyperactivity disorder and/or oppositional defiant disorder, and no disorder. RESULTS A hierarchy in severity emerged, with significant differences among all four groups. Preschoolers meeting standard criteria displayed the highest severity, followed by those who met modified criteria. Both depressed groups had significantly higher severity than the two comparison groups. CONCLUSIONS Standard DSM-IV criteria captured the most severely affected preschoolers, missing a substantial proportion of children with potentially clinically significant but less severe symptoms who were captured by modified DSM-IV criteria.
Collapse
Affiliation(s)
- Joan L Luby
- Department of Psychiatry, Washington university School of Medicine, AMO 63110, USA.
| | | | | | | | | | | |
Collapse
|
21
|
Abstract
OBJECTIVE To investigate the clinical characteristics of depression in preschool children. METHOD One hundred seventy-four subjects between the ages of 3.0 and 5.6 years were ascertained from community and clinical sites for a comprehensive assessment that included an age-appropriate psychiatric interview for parents. Modifications were made to the assessment of major depressive disorder (MDD) criteria so that age-appropriate manifestations of symptom states could be captured. Typical and "masked" symptoms of depression were investigated in three groups: depressed (who met all MDD criteria except duration criterion), those with nonaffective psychiatric disorders (who met criteria for attention-deficit/hyperactivity disorder and/or oppositional defiant disorder), and those who did not meet criteria for any psychiatric disorder. RESULTS Depressed preschool children displayed "typical" symptoms and vegetative signs of depression more frequently than other nonaffective or "masked" symptoms. Anhedonia appeared to be a specific symptom and sadness/irritability appeared to be a sensitive symptom of preschool MDD. CONCLUSIONS Clinicians should be alert to age-appropriate manifestations of typical MDD symptoms and vegetative signs when assessing preschool children for depression. "Masked" symptoms of depression occur in preschool children but do not predominate the clinical picture. Future studies specifically designed to investigate the specificity and sensitivity of the symptoms of preschool depression are now warranted.
Collapse
Affiliation(s)
- Joan L Luby
- Washington University School of Medicine, Department of Psychiatry, St. Louis, MO 63110, USA.
| | | | | | | | | | | | | |
Collapse
|
22
|
Luby JL, Heffelfinger AK, Mrakotsky C, Hessler MJ, Brown KM, Hildebrand T. Preschool major depressive disorder: preliminary validation for developmentally modified DSM-IV criteria. J Am Acad Child Adolesc Psychiatry 2002; 41:928-37. [PMID: 12162628 DOI: 10.1097/00004583-200208000-00011] [Citation(s) in RCA: 144] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To investigate the validity of developmentally modified DSM-IV criteria for preschool major depressive disorder (MDD). METHOD Subjects between the ages of 3.0 and 5.6 years were ascertained from community and clinical sites for a comprehensive assessment that included an age-appropriate psychiatric interview with the parent about the child. Minor developmental modifications to the formal DSM-IV MDD criteria were tested, including translations of symptoms to describe age-appropriate manifestations and setting aside the duration criterion. Preschool children who met modified criteria were compared with psychiatric and normal control groups. RESULTS Validation for the modified criteria was supported by a specific and stable symptom constellation, social impairment, greater family histories of affective disorders, and higher child-reported symptoms of depression on an age-appropriate puppet interview. Preschool children with MDD displayed "typical" symptoms of depression, as well as vegetative signs. Standard DSM-IV criteria failed to capture 76% of children who met these modified criteria. CONCLUSIONS Evidence that preschool children can manifest typical symptoms of MDD when age-adjusted symptoms states are assessed is provided. Findings also suggest that standard DSM-/V criteria may not be sufficiently sensitive for preschool children, as they failed to capture a substantial proportion of symptomatic children. Minor modifications to DSM-IV criteria are recommended to capture clinically significant preschool MDD.
Collapse
Affiliation(s)
- Joan L Luby
- Department of Psychiatry, Washington University School of Medicine, St Louis, MO 63110, USA.
| | | | | | | | | | | |
Collapse
|