The coronavirus disease 2019 (COVID-19) is profoundly affecting life around the globe. Isolation, contact restrictions and economic shutdown impose a complete change to the psychosocial environment ...in affected countries. These measures have the potential to threaten the mental health of children and adolescents significantly. Even though the current crisis can bring with it opportunities for personal growth and family cohesion, disadvantages may outweigh these benefits. Anxiety, lack of peer contact and reduced opportunities for stress regulation are main concerns. Another main threat is an increased risk for parental mental illness, domestic violence and child maltreatment. Especially for children and adolescents with special needs or disadvantages, such as disabilities, trauma experiences, already existing mental health problems, migrant background and low socioeconomic status, this may be a particularly challenging time. To maintain regular and emergency child and adolescent psychiatric treatment during the pandemic is a major challenge but is necessary for limiting long-term consequences for the mental health of children and adolescents. Urgent research questions comprise understanding the mental health effects of social distancing and economic pressure, identifying risk and resilience factors, and preventing long-term consequences, including-but not restricted to-child maltreatment. The efficacy of telepsychiatry is another highly relevant issue is to evaluate the efficacy of telehealth and perfect its applications to child and adolescent psychiatry.
There are numerous mental health threats associated with the current pandemic and subsequent restrictions. Child and adolescent psychiatrists must ensure continuity of care during all phases of the pandemic. COVID-19-associated mental health risks will disproportionately hit children and adolescents who are already disadvantaged and marginalized. Research is needed to assess the implications of policies enacted to contain the pandemic on mental health of children and adolescents, and to estimate the risk/benefit ratio of measures such as home schooling, in order to be better prepared for future developments.
The authors examined the utilization of stimulant medications for the treatment of ADHD in U.S. children during the period 1996–2008 to determine trends by age, sex, race/ethnicity, family income, ...and geographic region.
The 1996–2008 database of the Medical Expenditure Panel Survey, a nationally representative annual survey of U.S. households, was analyzed for therapeutic stimulant use in children age 18 and younger. The data for 1987 were also recalculated for reference.
An estimated 3.5% (95% confidence interval=3.0–4.1) of U.S. children received stimulant medication in 2008, up from 2.4% in 1996. Over the period 1996–2008, stimulant use increased consistently at an overall annual growth rate of 3.4%. Use increased in adolescents (annual growth, 6.5%), but it did not significantly change in 6- to 12-year-olds, and it decreased in preschoolers. Use remained higher in boys than in girls, and it remained consistently lower in the West than in other U.S. regions. While differences by family income have disappeared over time, use of stimulants in ADHD treatment is significantly lower in racial/ethnic minorities.
Overall, pediatric stimulant use has been slowly but steadily increasing since 1996, primarily as a result of greater use in adolescents. Use in preschoolers remains low and has declined over time. Important variations related to racial/ethnic background and geographic region persist, thus indicating a substantial heterogeneity in the approach to the treatment of ADHD in U.S. communities.
The coronavirus disease 2019 (COVID-19) pandemic has abruptly changed the life of millions as travel and social contacts have been severely restricted. We assessed the psychological impact of ...COVID-19 on adults and children, with special attention to health care workers (HCWs).
A self-rated online survey, including the Impact of Event Scale-Revised (IES-R) for adults and the Children Revised Impact of Event Scale-Revised-13 items (CRIES-13) for their 8-18-year-old offspring, was conducted in Italy on March 20-26, 2020. Linear mixed-effects models were applied to the data, accounting for age, sex, education, and other demographic characteristics.
Data were available from 2,419 adults (78.4% females, mean age 38.1 ± SD 13.1 years; 15.7% HCW) and 786 children (50.1% male, mean age 12.3 ± 3.2 years). Median (IQR) IES-R score was 30.0 (21.0-40.0), corresponding to mild psychological impact, with 33.2% reporting severe psychological impact. IES-R was lower in HCWs (29.0) than non-HCWs (31.0), but HCWs directly involved in COVID-19 care had higher scores 33.0 (26.0-43.2) than uninvolved HCWs 28.0 (19.0-36.0). Median CRIES-13 score was 21.0 (11.0-32.0), with 30.9% of the children at high risk for post-traumatic stress disorder. Parent and child scores were correlated.
Up to 30% of adult and children in the pandemic area are at high risk for post-traumatic stress disturbances. The risk is greater for HCWs directly involved in COVID-19 care and for their children.
Autism Spectrum Disorder (ASD) is a severe and lifelong neurodevelopmental disorder, with high social costs and a dramatic burden on the quality of life of patients and family members. Despite its ...high prevalence, reaching 1/54 children and 1/45 adults in the United States, no pharmacological treatment is still directed to core symptoms of ASD, encompassing social and communication deficits, repetitive behaviors, restricted interests, and abnormal sensory processing. The purpose of this review is to provide an overview of the state-of-the-art of psychopharmacological therapy available today for ASD in children and adolescents, in order to foster best practices and to organize new strategies for future research. To date, atypical antipsychotics such as risperidone and aripiprazole represent the first line of intervention for hyperactivity, impulsivity, agitation, temper outbursts or aggression towards self or others. Tricyclic antidepressants are less prescribed because of uncertain efficacy and important side effects. SSRIs, especially fluoxetine and sertraline, may be effective in treating repetitive behaviors (anxiety and obsessive-compulsive symptoms) and irritability/agitation, while mirtazapine is more helpful with sleep problems. Low doses of buspirone have shown some efficacy on restrictive and repetitive behaviors in combination with behavioral interventions. Stimulants, and to a lesser extent atomoxetine, are effective in reducing hyperactivity, inattention and impulsivity also in comorbid ASD-ADHD, although with somewhat lower efficacy and greater incidence of side effects compared to idiopathic ADHD. Clonidine and guanfacine display some efficacy on hyperactivity and stereotypic behaviors. For several other drugs, case reports and open-label studies suggest possible efficacy, but no randomized controlled trial has yet been performed. Research in the pediatric psychopharmacology of ASD is still faced with at least two major hurdles: (a) Great interindividual variability in clinical response and side effect sensitivity is observed in the ASD population. This low level of predictability would benefit from symptom-specific treatment algorithms and from biomarkers to support drug choice; (b) To this date, no psychoactive drug appears to directly ameliorate core autism symptoms, although some indirect improvement has been reported with several drugs, once the comorbid target symptom is abated.
•The pediatric psychopharmacology of ASD is systematically reviewed.•Tryciclics, neuroleptics and naltrexone were first-line treatments until the 90’s.•Second generation antipsychotics and other drugs have since become first-line treatments.•Psychoactive drugs directly ameliorate co-morbid and not core ASD symptoms.•Great interindividual variability in sensitivity to therapeutic and adverse effects.
The relationship between population density and suicide risk remains unclear. While urbanization is associated with greater risk for psychopathology, higher suicide rates have been reported in rural ...areas. We examined population density and suicide in the Italian population in the last 30 years.
The Italian National Institute of Statistics databases of the Italian population aged 15 years and older (52.4 million in 2016) were used to compute age-adjusted annual total mortality and suicide rates for the years 1985-2016. According to the European Union statistical office (EUROSTAT) criteria, municipalities were classified into densely populated areas, intermediate density areas, or thinly populated areas. Rate ratios (RRs) were computed by sex, age, and geographical area, using densely populated areas as reference.
Total mortality was not associated with population density. In males, suicide rate increased with decreasing population density (RR = 1.17, 95% confidence interval CI:1.08-1.28, in intermediate population areas, and RR = 1.32, 95% CI: 1.20-1.45, in thinly populated areas, in 2016). This inverse relationship was found across age, geographical areas, and consecutively over 22 years (1994-2016). In females, no significant difference was detected (RR = 0.96, 95% CI: 0.82-1.13 in intermediate density areas and RR = 1.02, 95% CI: 0.85-1.22 in thinly populated areas). Hanging was the most common suicide method among males, more frequent in thinly (58.8%) than intermediate (53.2%) or densely (41.4%) populated areas.
A consistent and temporally stable inverse relationship between population density and suicide was found in the male, but not female, population. Men may be more vulnerable to adverse social and economic factors associated with lower population density.
Objective: To evaluate the clinical and prognostic significance of suicide attempts (SAs) and nonsuicidal self-injury (NSSI) in adolescents with treatment-resistant depression. Method: Depressed ...adolescents who did not improve with an adequate SSRI trial (N = 334) were randomized to a medication switch (SSRI or venlafaxine), with or without cognitive-behavioral therapy. NSSI and SAs were assessed at baseline and throughout the 24-week treatment period. Results: Of the youths, 47.4% reported a history of self-injurious behavior at baseline: 23.9% NSSI alone, 14% NSSI+SAs, and 9.5% SAs alone. The 24-week incidence rates of SAs and NSSI were 7% and 11%, respectively; these rates were highest among youths with NSSI+SAs at baseline. NSSI history predicted both incident SAs (hazard ratio HR= 5.28, 95% confidence interval CI = 1.80-15.47, z = 3.04, p = 0.002) and incident NSSI (HR = 7.31, z = 4.19, 95% CI = 2.88-18.54, p less than 0.001) through week 24, and was a stronger predictor of future attempts than a history of SAs (HR = 1.92, 95% CI = 0.81-4.52, z = 2.29, p = 0.13). In the most parsimonious model predicting time to incident SAs, baseline NSSI history and hopelessness were significant predictors, adjusting for treatment effects. Parallel analyses predicting time to incident NSSI through week 24 identified baseline NSSI history and physical and/or sexual abuse history as significant predictors. Conclusions: NSSI is a common problem among youths with treatment-resistant depression and is a significant predictor of future SAs and NSSI, underscoring the critical need for strategies that target the prevention of both NSSI and suicidal behavior. Clinical Trial Registration Information: Treatment of SSRI-Resistant Depression in Adolescents (TORDIA), NCT00018902. (Contains 2 figures and 2 tables.)
Anorexia nervosa (AN) is a serious mental illness of growing prevalence in childhood and adolescence. Despite its severity, there are still no completely satisfactory evidence-based treatments. ...Follow-up studies represent the most effective attempt to enlighten treatment effectiveness, outcome predictors and process indicators.
Seventy-three female participants affected with AN were assessed at intake (T0) and at 6 (T1) and 12 (T2) months of an outpatient multimodal treatment program. Nineteen participants were assessed 15 years after discharge (T3). Changes in diagnostic criteria were compared with the chi-square test. Clinical, personality and psychopathology evolution were tested with ANOVA for repeated measures, using the t-test or Wilcoxon test as post-hoc. T0 features among dropout, stable and healed participants were compared. Healed and unhealed groups at long-term follow-up were compared using Mann-Whitney U test. Treatment changes were correlated to each other and with intake features using multivariate regression.
The rate of complete remission was 64.4% at T2, and 73.7% at T3. 22% of participants maintained a full diagnosis at T2, and only 15.8% at T3. BMI significantly increased at each time-point. A significant decrease of persistence and increase in self-directedness were evidenced between T0 and T2. Interoceptive awareness, drive to thinness, impulsivity, parent-rated, and adolescent-rated general psychopathology significantly decreased after treatment. Lower reward dependence and lower cooperativeness characterized the dropout group. The healed group displayed lower adolescent-rated aggressive and externalizing symptoms, and lower parent-rated delinquent behaviors. BMI, personality and psychopathology changes were related with each other and with BMI, personality and psychopathology at intake.
A 12-months outpatient multimodal treatment encompassing psychiatric, nutritional and psychological approaches is an effective approach for the treatment of mild to moderate AN in adolescence. Treatment was associated not only with increased BMI but also with positive personality development, and changes in both eating and general psychopathology. Lower relational abilities may be an obstacle to healing. Approaches to treatment resistance should be personalized according to these finding.
Parenting gender diverse children and adolescents can be a challenging experience, entailing doubts about how to protect and support them during their development. Parental reactions impact on the ...child’s sense of security and well-being. Therefore, when caring for families with gender diverse children, it is important to offer support to parents. In this article we present an experience with a 12-month support group for parents of young people who attended the service for gender identity development at a paediatric hospital. We describe the group structure and methodology, together with the process for evaluating the intervention. At 6-month intervals, parents were asked to indicate the most important topics that had emerged during the monthly sessions. At 12 months, they completed a semi-structured feedback questionnaire about their experience in the group, including possible difficulties encountered. Thematic analysis showed an evolution in time, with participants taking a more complex perspective on gender diversity and the needs of their children, while feeling more able to deal with the uncertainties related to gender identity development. After attending the group, parents reported feeling less lonely, more confident, and better able to communicate with their children. They related these positive changes to the opportunity of sharing experiences and mutual learning. This feed-back provides preliminary evidence that the psychological support group was perceived to be a useful resource by parents of gender diverse young people.
There is a strong tradition in child mental health of developing measures to assess both general psychopathology and specific constructs such as attention-deficit/hyperactivity disorder, autism, ...depression, anxiety, and obsessive-compulsive disorder. For psychosis, however, the tendency has been to use in children instruments that were developed for adults, such as the Positive and Negative Syndrome Scale (PANSS). There are general good reasons for using the same assessment tools in youth as in adults, because this facilitates comparisons across the lifespan. In the case of schizophrenia, in particular, there is evidence of continuity of psychopathology from adolescence to adulthood. There are also practical reasons why an instrument such as the PANSS, which has been widely used in research and accepted by drug regulatory agencies, has remained unchanged over time. The PANSS has consistently been shown to be able to discriminate between antipsychotic medication and placebo in adults, children, and adolescents.
Keeping the same rating instrument across studies and over time also facilitates comparisons between clinical trials and medications, allows possible time trends in treatment effect to be detected, and helps systematic reviews and meta-analyses.
The drawback of this methodological conservatism is that it provides little motivation to perfect the existing tools for measuring psychopathology, with negative impact on both research and clinical practice.
The effects of stimulant medications and atomoxetine on physical growth and on cardiovascular function are reviewed in light of the most recent data, with attention to clinical implications and ...research needs. Although these medications have a favorable benefit/risk profile and do not induce clinically significant changes in growth or cardiovascular function in the majority of cases, careful patient monitoring is needed to identify individuals at risk for negative outcomes. More research is needed to elucidate the mechanism of growth suppression to estimate better the risk for rare but life-threatening events and test the effectiveness of monitoring procedures.
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